Provider Demographics
NPI:1477286417
Name:DIXON, JACQUELINE (OTA11743)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:OTA11743
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7379 NW 34TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4962
Mailing Address - Country:US
Mailing Address - Phone:954-861-8611
Mailing Address - Fax:
Practice Address - Street 1:7379 NW 34TH ST
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33319-4962
Practice Address - Country:US
Practice Address - Phone:954-861-8611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11743224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant