Provider Demographics
NPI:1144540790
Name:JACKSON, LYLE THOMAS JR (MD)
Entity type:Individual
Prefix:
First Name:LYLE
Middle Name:THOMAS
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 COBURG RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2433
Mailing Address - Country:US
Mailing Address - Phone:541-485-8111
Mailing Address - Fax:541-342-6379
Practice Address - Street 1:55 COBURG RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2433
Practice Address - Country:US
Practice Address - Phone:541-485-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-06
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16057207XX0004X, 207X00000X
ORMD176209207XX0004X
SC32738207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1144540790Medicaid
NVV112329Medicare PIN