Provider Demographics
NPI:1205198025
Name:JACKSON, DARRYL RAYNOR JR
Entity Type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:RAYNOR
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-4025
Mailing Address - Country:US
Mailing Address - Phone:573-629-0321
Mailing Address - Fax:
Practice Address - Street 1:1734 MARKET ST
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-4025
Practice Address - Country:US
Practice Address - Phone:573-629-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO201000472224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant