Healthcare Provider Details

I. General information

NPI: 1538200068
Provider Name (Legal Business Name): JACQUELINE DEANNA KNOWLES OTR, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GLENDON CT
DUBLIN OH
43016-3249
US

IV. Provider business mailing address

5945 MARYLEW LN
DAYTON OH
45415-1644
US

V. Phone/Fax

Practice location:
  • Phone: 937-890-7039
  • Fax: 937-890-7043
Mailing address:
  • Phone: 937-898-7753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT - 001165
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number00046254
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: