Healthcare Provider Details

I. General information

NPI: 1760517999
Provider Name (Legal Business Name): KAREN SYDNI JACKSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 NATIONWIDE DR
LYNCHBURG VA
24502-4272
US

IV. Provider business mailing address

1482 LAKE SHORE DR
FOREST VA
24551-2131
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-6933
  • Fax:
Mailing address:
  • Phone: 434-414-0632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000732
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: