Provider Demographics
NPI:1255766002
Name:JACKSON, ELIZABETH ANN (COTA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
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 1:110 E MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LIBERTY MILLS
Mailing Address - State:IN
Mailing Address - Zip Code:46946-0000
Mailing Address - Country:US
Mailing Address - Phone:260-578-1380
Mailing Address - Fax:
Practice Address - Street 1:300 E PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-4429
Practice Address - Country:US
Practice Address - Phone:260-578-1380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001765A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant