Provider Demographics
NPI:1285127506
Name:JACKSON, JACQUELINE NICHOLE (COTA)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:NICHOLE
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 1:626 N TYNDALL PKWY
Mailing Address - Street 2:
Mailing Address - City:CALLAWAY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-6132
Mailing Address - Country:US
Mailing Address - Phone:850-871-6363
Mailing Address - Fax:
Practice Address - Street 1:626 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:CALLAWAY
Practice Address - State:FL
Practice Address - Zip Code:32404-6132
Practice Address - Country:US
Practice Address - Phone:850-871-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15305224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant