Provider Demographics
NPI:1093139081
Name:EUBANK, JACQUELINE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:EUBANK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44308-1911
Mailing Address - Country:US
Mailing Address - Phone:330-761-1661
Mailing Address - Fax:
Practice Address - Street 1:70 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1911
Practice Address - Country:US
Practice Address - Phone:330-761-1661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA01392224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant