Provider Demographics
NPI:1275655482
Name:JACKSON, DOUGLENE J (PHD, OTR/L, LMT, ATP)
Entity Type:Individual
Prefix:
First Name:DOUGLENE
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD, OTR/L, LMT, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 NW 207TH WAY
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3509
Mailing Address - Country:US
Mailing Address - Phone:678-472-3201
Mailing Address - Fax:
Practice Address - Street 1:240 NW 207TH WAY
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3509
Practice Address - Country:US
Practice Address - Phone:678-472-3201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29727225700000X
GAOT003627225X00000X
247200000X
FLOT10451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other