Provider Demographics
NPI:1770607319
Name:JACKSON, DIANE JANE (OTR)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:JANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 PENACOOK RD
Mailing Address - Street 2:
Mailing Address - City:CONTOOCOOK
Mailing Address - State:NH
Mailing Address - Zip Code:03229-3016
Mailing Address - Country:US
Mailing Address - Phone:603-746-2439
Mailing Address - Fax:
Practice Address - Street 1:239 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7504
Practice Address - Country:US
Practice Address - Phone:603-224-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1133225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist