Provider Demographics
NPI:1821129214
Name:JACKSON, VALERIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:
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 1:3488 JEFFCO BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-6015
Mailing Address - Country:US
Mailing Address - Phone:813-476-1674
Mailing Address - Fax:
Practice Address - Street 1:3488 JEFFCO BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6015
Practice Address - Country:US
Practice Address - Phone:813-476-1674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003024194225X00000X
MO2015009938225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist