Provider Demographics
NPI:1629778055
Name:JACKSON, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 GRASSHOPPER RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-9385
Mailing Address - Country:US
Mailing Address - Phone:919-417-7547
Mailing Address - Fax:
Practice Address - Street 1:601 MARTIN LUTHER KING JR. DR
Practice Address - Street 2:432 FL ATKINS BUILDING
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-0001
Practice Address - Country:US
Practice Address - Phone:919-417-7547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist