Provider Demographics
NPI:1003381054
Name:JACKSON, BRIANA (M OTR/L)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:M OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 VALLEY AVE APT 102A
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:ND
Mailing Address - Zip Code:58722-2026
Mailing Address - Country:US
Mailing Address - Phone:701-391-2263
Mailing Address - Fax:
Practice Address - Street 1:3120 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2811
Practice Address - Country:US
Practice Address - Phone:701-720-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics