Provider Demographics
NPI:1124757463
Name:JACKSON, BRIYANA J (OTR/L)
Entity type:Individual
Prefix:
First Name:BRIYANA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
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 1:600 STILLWATER LANDING WAY APT 207
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-6931
Mailing Address - Country:US
Mailing Address - Phone:434-579-3386
Mailing Address - Fax:
Practice Address - Street 1:101 N PLAIN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6760
Practice Address - Country:US
Practice Address - Phone:910-298-2331
Practice Address - Fax:910-375-3031
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009500225X00000X
NC15540225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist