Provider Demographics
NPI:1063285880
Name:PINKSTON, JACE BRANDON (OTR/L)
Entity type:Individual
Prefix:MR
First Name:JACE
Middle Name:BRANDON
Last Name:PINKSTON
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 1:606 MARLOWS FORD RD APT 101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4767
Mailing Address - Country:US
Mailing Address - Phone:270-957-6003
Mailing Address - Fax:
Practice Address - Street 1:2420 WILSON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2135
Practice Address - Country:US
Practice Address - Phone:812-265-8226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY288914225X00000X
IN31008247A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist