Provider Demographics
NPI:1497523641
Name:JACKSON, CHANTE OLIVIA (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:CHANTE
Middle Name:OLIVIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25330 W 6 MILE RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2105
Mailing Address - Country:US
Mailing Address - Phone:313-531-6874
Mailing Address - Fax:
Practice Address - Street 1:16112 MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3188
Practice Address - Country:US
Practice Address - Phone:313-617-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202006981225X00000X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist