Provider Demographics
NPI:1841782398
Name:JACKSON, CHRYSTAL MAE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CHRYSTAL
Middle Name:MAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:CHRYSTAL
Other - Middle Name:MAE
Other - Last Name:WOLVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:640 BENT OAK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-4230
Mailing Address - Country:US
Mailing Address - Phone:806-433-8191
Mailing Address - Fax:
Practice Address - Street 1:5417 ALTAMESA BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-2804
Practice Address - Country:US
Practice Address - Phone:866-980-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210256224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant