Provider Demographics
NPI:1356661375
Name:ADAMS, JACQUELINE JO (COTA/L)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JO
Last Name:ADAMS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:JO
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L
Mailing Address - Street 1:501 N CANEY ST
Mailing Address - Street 2:
Mailing Address - City:COPAN
Mailing Address - State:OK
Mailing Address - Zip Code:74022-4221
Mailing Address - Country:US
Mailing Address - Phone:580-763-2480
Mailing Address - Fax:
Practice Address - Street 1:501 N CANEY ST
Practice Address - Street 2:
Practice Address - City:COPAN
Practice Address - State:OK
Practice Address - Zip Code:74022-4221
Practice Address - Country:US
Practice Address - Phone:580-763-2480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK757224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant