Provider Demographics
NPI:1003009937
Name:JACKSON, KEITH R (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:R
Last Name:JACKSON
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 1:4024 EAGLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-5619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 NORTH BLVD W
Practice Address - Street 2:SUITE D
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5063
Practice Address - Country:US
Practice Address - Phone:352-787-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9471225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist