Provider Demographics
NPI:1962250225
Name:JACKSON, CAREY II
Entity type:Individual
Prefix:
First Name:CAREY
Middle Name:
Last Name:JACKSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38075-4708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 MAPLE ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38075-4708
Practice Address - Country:US
Practice Address - Phone:731-212-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1231901241233737225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist