Provider Demographics
NPI:1598903742
Name:JACKSON, KELLY JEAN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:GAILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:280 E MAIN ST
Mailing Address - Street 2:SUITE 132
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-7333
Mailing Address - Country:US
Mailing Address - Phone:302-709-0440
Mailing Address - Fax:302-709-0443
Practice Address - Street 1:280 E MAIN ST
Practice Address - Street 2:SUITE 132
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7333
Practice Address - Country:US
Practice Address - Phone:302-709-0440
Practice Address - Fax:302-709-0443
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU20000941224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant