Provider Demographics
NPI:1841479342
Name:JACKSON, SHAWN NICHOLE (COTA)
Entity type:Individual
Prefix:MISS
First Name:SHAWN
Middle Name:NICHOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:9252 ASHLAND WOODS LN
Mailing Address - Street 2:APT A2
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1805
Mailing Address - Country:US
Mailing Address - Phone:703-339-0534
Mailing Address - Fax:
Practice Address - Street 1:1415 ROUTE 70 E
Practice Address - Street 2:SUITE 103
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2210
Practice Address - Country:US
Practice Address - Phone:800-670-3893
Practice Address - Fax:856-482-8498
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant