Individual
RYAN JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
535 S ELM ST, ITASCA, IL 60143-2187
(630) 773-9416
Mailing address
19438 ELM DR, COUNTRY CLUB HILLS, IL 60478-5856
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
057005112
IL
Other
Enumeration date
02/25/2019
Last updated
02/25/2019
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