Provider Demographics
NPI:1972049294
Name:JACKS, JENNIFER (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JACKS
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 1:1707 REX AVE APT 161F
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-5940
Mailing Address - Country:US
Mailing Address - Phone:417-844-1415
Mailing Address - Fax:
Practice Address - Street 1:2700 E 34TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4310
Practice Address - Country:US
Practice Address - Phone:417-781-1737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024696224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant