Provider Demographics
NPI:1447585807
Name:JACKSON, DEANA K (MOT, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:DEANA
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-5529
Mailing Address - Country:US
Mailing Address - Phone:270-554-3135
Mailing Address - Fax:270-554-3136
Practice Address - Street 1:2500 MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-5529
Practice Address - Country:US
Practice Address - Phone:270-554-3135
Practice Address - Fax:270-554-3136
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3013225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100112930Medicaid