Provider Demographics
NPI:1427291731
Name:SANDS, JACKIE M (OTR)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:M
Last Name:SANDS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:JACKIE
Other - Middle Name:M
Other - Last Name:BEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:331 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-1726
Mailing Address - Country:US
Mailing Address - Phone:608-366-6239
Mailing Address - Fax:
Practice Address - Street 1:331 S WATER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1726
Practice Address - Country:US
Practice Address - Phone:608-269-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4725-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist