Provider Demographics
NPI:1861889321
Name:JACKSON, JENNIFER (OTR)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3864 SWEETEN CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704
Mailing Address - Country:US
Mailing Address - Phone:828-575-6128
Mailing Address - Fax:610-612-3019
Practice Address - Street 1:3864 SWEETEN CREEK ROAD
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704
Practice Address - Country:US
Practice Address - Phone:828-681-0904
Practice Address - Fax:610-612-3019
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005789225X00000X
NC10382225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist