Provider Demographics
NPI:1457429011
Name:JACKSON, AMANDA Z (OT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:Z
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2650 WEIGELIA RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3969
Mailing Address - Country:US
Mailing Address - Phone:404-633-9955
Mailing Address - Fax:404-633-4271
Practice Address - Street 1:575 DEKALB INDUSTRIAL WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1756
Practice Address - Country:US
Practice Address - Phone:404-296-8511
Practice Address - Fax:404-296-8514
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002496225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist