Provider Demographics
NPI:1194207555
Name:MARQUEZ, JACKIE DEE (COTA)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:DEE
Last Name:MARQUEZ
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 1:4614 STONEGATE WAY
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411
Mailing Address - Country:US
Mailing Address - Phone:361-658-7153
Mailing Address - Fax:
Practice Address - Street 1:219 N KING ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4841
Practice Address - Country:US
Practice Address - Phone:361-664-4366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209989224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant