Basic Information
| Provider Information | |||||||||
| NPI: | 1356621163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | STEWART | ||||||||
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| Credential: | MA, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2483 BURKE MEMORIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | VALDESE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286909435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049171801 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1899 TATE BLVD SE STE 2106 | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283580976 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1738 | WV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OTR2444 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 12625 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.