Provider Demographics
NPI:1588212872
Name:JACKSON, DIANE MARIE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 ELMHURST DR NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4760
Mailing Address - Country:US
Mailing Address - Phone:716-861-6836
Mailing Address - Fax:
Practice Address - Street 1:1279 ELMHURST DR NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4760
Practice Address - Country:US
Practice Address - Phone:716-861-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087310225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist