Provider Demographics
NPI:1659537512
Name:JACKSON, CRAIG (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 CASTLEREAGH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-6134
Mailing Address - Country:US
Mailing Address - Phone:843-819-9470
Mailing Address - Fax:877-286-5727
Practice Address - Street 1:2423 CASTLEREAGH RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-6134
Practice Address - Country:US
Practice Address - Phone:843-819-9470
Practice Address - Fax:877-286-5727
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC981224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
979693OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY, INC
SC981OtherSTATE OF SC DEPT OF LABOR, LICENSING AND REGULATION BOARD OF OT EXAMINERS