Provider Demographics
NPI:1720368616
Name:JACKSON, CANDICE ELIZABETH (COTA/L)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-6637
Mailing Address - Country:US
Mailing Address - Phone:217-254-6383
Mailing Address - Fax:
Practice Address - Street 1:216 UNION CHURCH RD
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NC
Practice Address - Zip Code:28327-7644
Practice Address - Country:US
Practice Address - Phone:910-585-1912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8007224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8007OtherNC BOARD OF OCCUPATIONAL THERAPY