Provider Demographics
NPI:1225202393
Name:JACKSON, STACIE W (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:W
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 1:719 HERITAGE PARK LN
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-4198
Mailing Address - Country:US
Mailing Address - Phone:205-266-5394
Mailing Address - Fax:
Practice Address - Street 1:719 HERITAGE PARK LN
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226-4198
Practice Address - Country:US
Practice Address - Phone:205-266-5394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2276225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2276OtherOT LICENSE