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NPI Code Detail

MEDICARE: ELIZABETH LANE JACKSON OTD

MEDICARE: ELIZABETH LANE JACKSON OTD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225X00000XOccupational Therapist

General Provider Information

NPI Number : 1619801164
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELIZABETH LANE JACKSON OTD
Provider Business Mailing Address
First Line : 1185 W MOUNTAIN VIEW RD APT 2313
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37604-2539
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2214 E FAIRVIEW AVE
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37601-2860
Country : US
Telephone Number : 423-928-6464
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2026
Last Update Date : 06/10/2026

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Directions to “ ELIZABETH LANE JACKSON OTD” Practice Location

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