Provider Demographics
NPI:1780841684
Name:JACKSON, MARK R (OT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1513
Mailing Address - Country:US
Mailing Address - Phone:877-407-3422
Mailing Address - Fax:877-407-4329
Practice Address - Street 1:801 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1513
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:877-407-4329
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC006680L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist