Provider Demographics
NPI:1700301132
Name:CRAIG, JACOB M (COTA/L)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:CRAIG
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 1:7585 BREMEN RD SE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-9426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 STATE ROUTE 664 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-8541
Practice Address - Country:US
Practice Address - Phone:740-380-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA006968224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant