Provider Demographics
NPI:1922471069
Name:JACKSON, PAMELA DEE (COTA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DEE
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 1:5051 BARCELONA TRL
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0937
Mailing Address - Country:US
Mailing Address - Phone:818-281-6582
Mailing Address - Fax:
Practice Address - Street 1:305 NE LOOP 820
Practice Address - Street 2:BUSINESS TOWER 1 SUITE 200
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-7209
Practice Address - Country:US
Practice Address - Phone:817-292-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213569224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant