Provider Demographics
NPI:1962863381
Name:JACKSON, CANDACE DORALEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:DORALEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 RANKIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-3806
Mailing Address - Country:US
Mailing Address - Phone:903-824-6589
Mailing Address - Fax:
Practice Address - Street 1:1470 RANKIN ST
Practice Address - Street 2:
Practice Address - City:ASHDOWN
Practice Address - State:AR
Practice Address - Zip Code:71822-3806
Practice Address - Country:US
Practice Address - Phone:903-824-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A 1072224Z00000X
TX213751224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant