Provider Demographics
NPI:1164691812
Name:DY JACKSON, MALY (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MALY
Middle Name:
Last Name:DY JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HOGAN DR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6410
Mailing Address - Country:US
Mailing Address - Phone:501-590-3334
Mailing Address - Fax:501-327-1601
Practice Address - Street 1:3605 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7377
Practice Address - Country:US
Practice Address - Phone:501-327-2235
Practice Address - Fax:501-327-1601
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR463225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist