Provider Demographics
NPI:1275264038
Name:JACKSON, REBECKA N (COTA)
Entity Type:Individual
Prefix:MISS
First Name:REBECKA
Middle Name:N
Last Name:JACKSON
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 1:319 WILDFIRE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-5248
Mailing Address - Country:US
Mailing Address - Phone:214-727-3111
Mailing Address - Fax:
Practice Address - Street 1:319 WILDFIRE DR
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-5248
Practice Address - Country:US
Practice Address - Phone:214-727-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214185224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty