Provider Demographics
NPI:1184830838
Name:JACKSON, SHENIKA LAVERNE (OT)
Entity Type:Individual
Prefix:
First Name:SHENIKA
Middle Name:LAVERNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 WINDING WAY APT A
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5097
Mailing Address - Country:US
Mailing Address - Phone:229-336-8255
Mailing Address - Fax:229-336-5878
Practice Address - Street 1:251 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1410
Practice Address - Country:US
Practice Address - Phone:229-336-8255
Practice Address - Fax:229-336-5878
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002552225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist