Healthcare Provider Details

I. General information

NPI: 1902981483
Provider Name (Legal Business Name): JASON DAVID ANDERSON OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 06/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505A ATLANTIC AVE
INTERLACHEN FL
32148-5433
US

IV. Provider business mailing address

420 NORTHSIDE DR
VALDOSTA GA
31602-1802
US

V. Phone/Fax

Practice location:
  • Phone: 386-684-9110
  • Fax:
Mailing address:
  • Phone: 229-333-8001
  • Fax: 229-333-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 10930
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: