Provider Demographics
NPI:1962529677
Name:JACKSON, SANDRA LYNN (COTA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
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 1:1614 CEDAR KNOLL AVE NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646
Mailing Address - Country:US
Mailing Address - Phone:330-830-3845
Mailing Address - Fax:
Practice Address - Street 1:435 AVIS AVE NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-3555
Practice Address - Country:US
Practice Address - Phone:330-837-1741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA706224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant