Provider Demographics
NPI:1215042379
Name:JACKSON, ERIN VICTORIA (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:ERIN
Middle Name:VICTORIA
Last Name: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 1:59 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:OTISFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04270-6442
Mailing Address - Country:US
Mailing Address - Phone:508-341-0601
Mailing Address - Fax:207-743-7063
Practice Address - Street 1:230 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5921
Practice Address - Country:US
Practice Address - Phone:508-341-0601
Practice Address - Fax:207-743-7063
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12164225X00000X
NC6944225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891136300Medicaid