Provider Demographics
NPI:1164989257
Name:JACKSON, RYAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JACKSON
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 1:19438 ELM DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-5856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:535 S ELM ST
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-2187
Practice Address - Country:US
Practice Address - Phone:630-773-9416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005112224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant