Provider Demographics
NPI:1710933981
Name:JACKSON, HEATHER C (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2882 NE COUNTY ROAD 354
Mailing Address - Street 2:
Mailing Address - City:MAYO
Mailing Address - State:FL
Mailing Address - Zip Code:32066-5327
Mailing Address - Country:US
Mailing Address - Phone:386-294-1952
Mailing Address - Fax:386-294-5002
Practice Address - Street 1:974 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MAYO
Practice Address - State:FL
Practice Address - Zip Code:32066-5631
Practice Address - Country:US
Practice Address - Phone:386-294-5000
Practice Address - Fax:386-294-5002
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT8375225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist