Provider Demographics
NPI:1568021475
Name:JACKSON, BRIANNA L (OT)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13271 OPAL CT
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-1681
Mailing Address - Country:US
Mailing Address - Phone:402-826-0414
Mailing Address - Fax:
Practice Address - Street 1:7010 15TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-5738
Practice Address - Country:US
Practice Address - Phone:727-200-4045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23818225X00000X
NE2309225X00000X
OK5335225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118446200Medicaid