Provider Demographics
NPI:1376104851
Name:JACKSON, KIMBERLY (OTR/L)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:CONDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1077 RIDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3238
Mailing Address - Country:US
Mailing Address - Phone:253-961-7303
Mailing Address - Fax:
Practice Address - Street 1:1219 DUNN AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2405
Practice Address - Country:US
Practice Address - Phone:386-255-4568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19785225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist