Provider Demographics
NPI:1144632837
Name:JACKSON, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6328 STATE ROUTE 283
Mailing Address - Street 2:
Mailing Address - City:SEBREE
Mailing Address - State:KY
Mailing Address - Zip Code:42455-9358
Mailing Address - Country:US
Mailing Address - Phone:270-835-2192
Mailing Address - Fax:
Practice Address - Street 1:303 NORTH HURSTBOURNE PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPTA-A01032225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant