Provider Demographics
NPI:1902981483
Name:ANDERSON, JASON DAVID (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:DAVID
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1802
Mailing Address - Country:US
Mailing Address - Phone:229-333-8001
Mailing Address - Fax:229-333-8333
Practice Address - Street 1:505A ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:INTERLACHEN
Practice Address - State:FL
Practice Address - Zip Code:32148-5433
Practice Address - Country:US
Practice Address - Phone:386-684-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 10930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist