Provider Demographics
NPI:1578880555
Name:JACKSON, KIA MARIA (COTA)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:MARIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3048 RIVER OAK MEWS
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6974
Mailing Address - Country:US
Mailing Address - Phone:404-245-4631
Mailing Address - Fax:
Practice Address - Street 1:3048 RIVER OAK MEWS
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-6974
Practice Address - Country:US
Practice Address - Phone:404-245-4631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000733224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant