Provider Demographics
NPI:1508984816
Name:JACKSON, ALEXIS MALAINA (OTR L)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MALAINA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 NATIONS DR
Practice Address - Street 2:SUITE 208
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-9168
Practice Address - Country:US
Practice Address - Phone:847-477-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics