Provider Demographics
NPI:1790972065
Name:DENIO-WAGGONER, JACKIE MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARIE
Last Name:DENIO-WAGGONER
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 1:3571 MAGELLAN CIR APT 347
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-3718
Mailing Address - Country:US
Mailing Address - Phone:308-933-9296
Mailing Address - Fax:305-933-9296
Practice Address - Street 1:3571 MAGELLAN CIR APT 347
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-3718
Practice Address - Country:US
Practice Address - Phone:308-933-9296
Practice Address - Fax:305-933-9296
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9046225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics