Provider Demographics
NPI:1205722014
Name:JACKSON, BRIAN (OTD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5406 MERSEA CT
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1929
Mailing Address - Country:US
Mailing Address - Phone:571-774-2867
Mailing Address - Fax:
Practice Address - Street 1:12581 MILSTEAD WAY STE 302
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5446
Practice Address - Country:US
Practice Address - Phone:703-239-7336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics