Provider Demographics
NPI:1063160992
Name:JACKSON, HALEY (COTA)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 SOUTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WINNEBAGO
Mailing Address - State:MO
Mailing Address - Zip Code:64034-7815
Mailing Address - Country:US
Mailing Address - Phone:913-749-7709
Mailing Address - Fax:
Practice Address - Street 1:12100 W 109TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-1200
Practice Address - Country:US
Practice Address - Phone:913-469-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01524224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant