Basic Information
| Provider Information | |||||||||
| NPI: | 1598059792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACK | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | HOWARD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | O.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOWARD | ||||||||
| OtherFirstName: | CAROLYN | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2526 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245402333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4348369510 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2526 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245402333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4348369510 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2011 | ||||||||
| LastUpdateDate: | 12/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119004889 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.