Provider Demographics
NPI:1396384939
Name:LAUS, JACKSON CABRERA (COTA/L)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:CABRERA
Last Name:LAUS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 RIVERSIDE DR APT 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-2166
Mailing Address - Country:US
Mailing Address - Phone:323-434-1414
Mailing Address - Fax:
Practice Address - Street 1:2800 RIVERSIDE DR APT 203
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-2166
Practice Address - Country:US
Practice Address - Phone:323-434-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4628224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty