Provider Demographics
NPI:1932579380
Name:JACKSON, LUCIA (LOT, CHT)
Entity type:Individual
Prefix:MS
First Name:LUCIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LOT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 E LAKE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:
Practice Address - Street 1:15476 DEDEAUX RD STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-215-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT-4216225X00000X
LAOTT.Z10872225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist