Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 16057 | NV |
N | 207X00000X | Orthopaedic Surgeon | 32738 | SC |
N | 207XX0004X | Foot and Ankle Orthopaedic Surgeon | 16057 | NV |
Y | 207XX0004X | Foot and Ankle Orthopaedic Surgeon | MD176209 | OR |
NPI | 1144540790 |
---|---|
Provider Name | Lyle Thomas Jackson JR. |
First Address | Eugene, OR 97401-2433 |
Second Address | Eugene, OR 97401-2433 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2010 |
Last Update Date | 28/07/2020 |