Provider Demographics
NPI:1750753208
Name:DAVIS, JACQUELINE (OT-A)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OT-A
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MORELOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6101 N STATE LINE AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5309
Mailing Address - Country:US
Mailing Address - Phone:903-791-2270
Mailing Address - Fax:903-792-0816
Practice Address - Street 1:6101 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-5309
Practice Address - Country:US
Practice Address - Phone:903-791-2270
Practice Address - Fax:903-792-0816
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211032224Z00000X
AROT-A644224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
278913OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY
AROT-A644OtherARKANSAS STATE MEDICIAL BOARD
TX211032OtherTEXAS BOARD OF OCCUPATIONAL THERAPY EXAMINERS