Provider Demographics
NPI:1700367349
Name:JACKSON, SUE LYON (LOTA)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:LYON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LOTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 HOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-4937
Mailing Address - Country:US
Mailing Address - Phone:254-897-2215
Mailing Address - Fax:254-897-2091
Practice Address - Street 1:1019 HOLDEN ST
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043-4937
Practice Address - Country:US
Practice Address - Phone:254-897-2215
Practice Address - Fax:254-897-2091
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204760224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant