Provider Demographics
NPI:1467607457
Name:JACKSON, LAUREN MARIE (MSOT, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 AUDUBON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1366
Mailing Address - Country:US
Mailing Address - Phone:502-724-2604
Mailing Address - Fax:
Practice Address - Street 1:4175 STONERIDGE LN
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2080
Practice Address - Country:US
Practice Address - Phone:502-724-2604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT009241225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist