=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992272959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACLYN CRADDOCK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2018
-----------------------------------------------------
Last Update Date | 10/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 889 BELL RD STE A
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37013-3101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-381-2195
-----------------------------------------------------
Fax | 888-381-0822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 SATELLITE BLVD STE 2250
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-381-2195
-----------------------------------------------------
Fax | 888-388-0822
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------