Provider Demographics
NPI:1598059792
Name:JACK, CAROLYN HOWARD (OT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:HOWARD
Last Name:JACK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:ANN
Other - Last Name:HOWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2526 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2333
Mailing Address - Country:US
Mailing Address - Phone:434-836-9510
Mailing Address - Fax:
Practice Address - Street 1:2526 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2333
Practice Address - Country:US
Practice Address - Phone:434-836-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-05
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004889225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist