Healthcare Provider Details

I. General information

NPI: 1144540790
Provider Name (Legal Business Name): LYLE THOMAS JACKSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2010
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 COBURG RD
EUGENE OR
97401-2433
US

IV. Provider business mailing address

55 COBURG RD
EUGENE OR
97401-2433
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-8111
  • Fax:
Mailing address:
  • Phone: 541-485-8111
  • Fax: 541-342-6379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number16057
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberMD176209
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number32738
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number16057
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: