Provider Demographics
NPI:1265887566
Name:SANDY, JACKIE (COTA, LPN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:SANDY
Suffix:
Gender:F
Credentials:COTA, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4942 ROUTE 309 LOT 375
Mailing Address - Street 2:
Mailing Address - City:CENTER VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18034-9497
Mailing Address - Country:US
Mailing Address - Phone:610-653-1241
Mailing Address - Fax:
Practice Address - Street 1:4942 ROUTE 309 LOT 375
Practice Address - Street 2:
Practice Address - City:CENTER VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18034-9497
Practice Address - Country:US
Practice Address - Phone:610-653-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007485224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant