Provider Demographics
NPI:1033386529
Name:JACK, CHARYL LADONNE JADA (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:CHARYL
Middle Name:LADONNE JADA
Last Name:JACK
Suffix:
Gender:F
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 1:1500 SHOREWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-2323
Mailing Address - Country:US
Mailing Address - Phone:360-670-9327
Mailing Address - Fax:360-343-1902
Practice Address - Street 1:1500 SHOREWOOD DR
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-2323
Practice Address - Country:US
Practice Address - Phone:360-670-9327
Practice Address - Fax:360-343-1902
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60003424225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8957STOtherREGENCE
WAG8875102Medicare UPIN