Provider Demographics
NPI:1255489324
Name:LACY, JASON DAVID (MSR, OTR-L, ATP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:DAVID
Last Name:LACY
Suffix:
Gender:M
Credentials:MSR, OTR-L, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 GLASS MILL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CHICKAMAUGA
Mailing Address - State:GA
Mailing Address - Zip Code:30707-3478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 GLASS MILL POINTE DR
Practice Address - Street 2:
Practice Address - City:CHICKAMAUGA
Practice Address - State:GA
Practice Address - Zip Code:30707-3478
Practice Address - Country:US
Practice Address - Phone:706-375-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT2656225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT3322OtherOT STATE LICENSE
TNOT2656OtherOT STATE LICENSE