Provider Demographics
NPI:1386168847
Name:JACKSON, BRENT CALEB (COTA/L)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:CALEB
Last Name:JACKSON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 HORN ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7138
Mailing Address - Country:US
Mailing Address - Phone:606-694-3187
Mailing Address - Fax:
Practice Address - Street 1:1100 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-1024
Practice Address - Country:US
Practice Address - Phone:606-836-3187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174107224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant