Provider Demographics
NPI:1659085207
Name:SIDES, JACKIE MARIE (OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARIE
Last Name:SIDES
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 POINTER RD
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:VA
Mailing Address - Zip Code:24520-3508
Mailing Address - Country:US
Mailing Address - Phone:757-448-5674
Mailing Address - Fax:
Practice Address - Street 1:165 HOLT GARRISON PKWY STE 595-A
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-5949
Practice Address - Country:US
Practice Address - Phone:434-688-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003320225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand