Provider Demographics
NPI:1780821165
Name:JACKSON, SARAH DANIELLE (OTA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:DANIELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:DANIELLE
Other - Last Name:JACKSON-JARVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:104 MULLEN DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-8047
Mailing Address - Country:US
Mailing Address - Phone:870-279-3150
Mailing Address - Fax:
Practice Address - Street 1:104 MULLEN DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-8047
Practice Address - Country:US
Practice Address - Phone:870-279-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A473224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant