Provider Demographics
NPI:1063566248
Name:FOX, JACQUELINE LISA (OTR)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LISA
Last Name:FOX
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LISA
Other - Last Name:FOX-LONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:24724 N 119TH PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-5928
Mailing Address - Country:US
Mailing Address - Phone:480-907-6292
Mailing Address - Fax:
Practice Address - Street 1:8115 E INDIAN BEND RD STE 123
Practice Address - Street 2:THERAPY REHABILITATION SERVICES
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-4819
Practice Address - Country:US
Practice Address - Phone:480-951-6451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA916948225X00000X
AZ3442225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist