Healthcare Provider Details

I. General information

NPI: 1578831020
Provider Name (Legal Business Name): JACLYN ANN CHRISTOFFERSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 FAIR ST
LEXINGTON NC
27292-1665
US

IV. Provider business mailing address

430 WILLOW RIDGE LN
WINSTON SALEM NC
27127-9239
US

V. Phone/Fax

Practice location:
  • Phone: 336-249-3206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6893
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: