Provider Demographics
NPI:1063619476
Name:JACKSON, KIMBERLY SMITH (LOTR)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SMITH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 RUBICH LN
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-1361
Mailing Address - Country:US
Mailing Address - Phone:985-643-2156
Mailing Address - Fax:
Practice Address - Street 1:2012 RUBICH LN
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-1361
Practice Address - Country:US
Practice Address - Phone:985-643-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200084225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist