Provider Demographics
NPI:1083041123
Name:JACKSON, PAMELA DIANNE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:DIANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:DIANNE
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:5400 WEST 87TH STREET
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459
Mailing Address - Country:US
Mailing Address - Phone:708-346-6236
Mailing Address - Fax:
Practice Address - Street 1:5400 W 87TH ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-2913
Practice Address - Country:US
Practice Address - Phone:708-346-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056001722225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist