Healthcare Provider Details

I. General information

NPI: 1821863010
Provider Name (Legal Business Name): BRENDA JACKSON OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 DULANEY VALLEY RD
TIMONIUM MD
21093-2700
US

IV. Provider business mailing address

5414 DAYWALT AVE
BALTIMORE MD
21206-4435
US

V. Phone/Fax

Practice location:
  • Phone: 410-252-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number03967
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: