Provider Demographics
NPI:1851459770
Name:JACKSON, NACOLE MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:NACOLE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 PLANETT ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-2682
Mailing Address - Country:US
Mailing Address - Phone:219-325-3541
Mailing Address - Fax:
Practice Address - Street 1:1120 S CALUMET RD
Practice Address - Street 2:SUITE 3
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3285
Practice Address - Country:US
Practice Address - Phone:219-983-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001281A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant