Provider Demographics
NPI:1538467899
Name:HOUTZ, JACKIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:HOUTZ
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 1:3756 GRACE FALLS DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-1576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3756 GRACE FALLS DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-1576
Practice Address - Country:US
Practice Address - Phone:615-426-4235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1902174400000X
CO3130174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist