Provider Demographics
NPI:1417067075
Name:JACKSON, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7035 STEINBECK BEND DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-5522
Mailing Address - Country:US
Mailing Address - Phone:254-752-0628
Mailing Address - Fax:
Practice Address - Street 1:7003 WOODWAY DR
Practice Address - Street 2:STE 305
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6170
Practice Address - Country:US
Practice Address - Phone:254-776-7864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103628OtherLICENSE #