Provider Demographics
NPI:1518432335
Name:MISTIATIS, JACKIE SUE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:SUE
Last Name:MISTIATIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:SUE
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:144 N MASTERS CT
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-3068
Mailing Address - Country:US
Mailing Address - Phone:419-973-3471
Mailing Address - Fax:
Practice Address - Street 1:725 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-3255
Practice Address - Country:US
Practice Address - Phone:419-435-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007265224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant