Provider Demographics
NPI:1356777411
Name:NICKSON, JACKIE D (OTD, OTR/L)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:D
Last Name:NICKSON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6664 SINCLAIR DR
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-2598
Mailing Address - Country:US
Mailing Address - Phone:901-230-4982
Mailing Address - Fax:662-393-2673
Practice Address - Street 1:6664 SINCLAIR DR
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-2598
Practice Address - Country:US
Practice Address - Phone:901-230-4982
Practice Address - Fax:662-393-2673
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-20
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1986225X00000X
MS1986225X00000X
MS225100000X, 235Z00000X, 224Z00000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty