MEDICARE: MR. GREGORY LEE JACKSON MS, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		KY

General Provider Information

NPI Number	:	1356306203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY LEE JACKSON MS, ATC

Provider Business Mailing Address
First Line	:	3821 EVERETTS DL
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40514-1185
Country	:	US
Telephone Number	:	859-351-6789
Fax Number	:

Provider Business Practice Location Address
First Line	:	3821 EVERETTS DL
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40514-1185
Country	:	US
Telephone Number	:	859-351-6789
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	07/08/2007

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