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Individual

MR. JASON DAVID LACY

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
MSR, OTR-L, ATP

Contact information

Practice address
74 GLASS MILL POINTE DR, CHICKAMAUGA, GA 30707-3478
(706) 375-3050
Mailing address
74 GLASS MILL POINTE DR, CHICKAMAUGA, GA 30707-3478

Taxonomy

Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT2656
TN

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
OT2656
OT STATE LICENSE
TN
01
OT3322
OT STATE LICENSE
GA
Enumeration date
01/08/2007
Last updated
07/08/2007
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