Provider Demographics
NPI:1578027736
Name:JACKSON, SHAWN RENE'E (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:SHAWN
Middle Name:RENE'E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-2736
Mailing Address - Country:US
Mailing Address - Phone:940-657-4500
Mailing Address - Fax:
Practice Address - Street 1:201 E THOMPSON ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-2736
Practice Address - Country:US
Practice Address - Phone:940-657-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211828224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant