Provider Demographics
NPI:1356621163
Name:ANDERSON, JACOB STEWART (MA, OTR/L)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:STEWART
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2483 BURKE MEMORIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:VALDESE
Mailing Address - State:NC
Mailing Address - Zip Code:28690-9435
Mailing Address - Country:US
Mailing Address - Phone:304-917-1801
Mailing Address - Fax:
Practice Address - Street 1:1899 TATE BLVD SE STE 2106
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602
Practice Address - Country:US
Practice Address - Phone:828-358-0976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1738225X00000X
AROTR2444225X00000X
NC12625225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist