Provider Demographics
NPI:1396382610
Name:PACK, JASON (COTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PACK
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9022 RICHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37924-4579
Mailing Address - Country:US
Mailing Address - Phone:865-279-6718
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:9022 RICHFIELD LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924-4579
Practice Address - Country:US
Practice Address - Phone:865-279-6718
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2473224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant