Provider Demographics
NPI:1588369383
Name:JACKSON, JESSICA LYNN (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:GODDARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2509 BLUESTEM RD
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-3246
Mailing Address - Country:US
Mailing Address - Phone:580-352-4998
Mailing Address - Fax:
Practice Address - Street 1:400 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-5429
Practice Address - Country:US
Practice Address - Phone:580-304-9767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1470224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant