=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528640844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOL J. JACOBS OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2021
-----------------------------------------------------
Last Update Date | 04/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10133 SHERRILL BLVD STE 200
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37932-3347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-247-6515
-----------------------------------------------------
Fax | 770-399-9787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10133 SHERRILL BLVD STE 200
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37932-3347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-247-6515
-----------------------------------------------------
Fax | 770-399-9787
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT008056
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------