Active NPI
Darryl Raynor Jackson Jr.
- Occupational Therapy Assistant
- Hannibal, MO
National Provider Identifier
1205198025
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapy Assistant
- License
- 201000472
- Practice address
- 1734 Market St
Hannibal, MO 63401-4025 - Phone
- (573) 629-0321
- NPI assigned
- Jun 8, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapy Assistant | 224Z00000X | 201000472 | MO | Primary |
Addresses
Primary practice location
1734 Market St
Hannibal, MO 63401-4025
Mailing address
1734 Market St
Hannibal, MO 63401-4025
Phone (573) 629-0321
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 201000472 | MO | MD | Occupational Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1339113600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1339113600000",
"number": "1205198025",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1734 MARKET ST",
"city": "HANNIBAL",
"state": "MO",
"postal_code": "634014025",
"telephone_number": "573-629-0321"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1734 MARKET ST",
"city": "HANNIBAL",
"state": "MO",
"postal_code": "634014025",
"telephone_number": "573-629-0321"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "DARRYL",
"middle_name": "RAYNOR",
"name_prefix": "Mr.",
"name_suffix": "Jr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-06-08",
"last_updated": "2012-06-08",
"status": "A"
},
"taxonomies": [
{
"code": "224Z00000X",
"taxonomy_group": "",
"desc": "Occupational Therapy Assistant",
"state": "MO",
"license": "201000472",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Hannibal, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 8, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.