Provider Demographics
NPI:1558666453
Name:JACKSON, NANCY C (OT)
Entity Type:Individual
Prefix:MISS
First Name:NANCY
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WATERVILLE RD
Mailing Address - Street 2:ALLSTAR
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2097
Mailing Address - Country:US
Mailing Address - Phone:860-678-9755
Mailing Address - Fax:
Practice Address - Street 1:21 WATERVILLE RD
Practice Address - Street 2:ALLSTAR
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-2097
Practice Address - Country:US
Practice Address - Phone:860-678-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003024225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist