Provider Demographics
NPI:1760516116
Name:JACKSON, JIMMY DEMARIO (OTRL)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:DEMARIO
Last Name:JACKSON
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 FILE ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3230
Mailing Address - Country:US
Mailing Address - Phone:336-331-2946
Mailing Address - Fax:
Practice Address - Street 1:5755 SHATTALON DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-1332
Practice Address - Country:US
Practice Address - Phone:336-744-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5827225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist