Provider Demographics
NPI:1134879422
Name:JACKSON, ANNIE (OTR/L)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:HELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8000
Mailing Address - Fax:616-840-9690
Practice Address - Street 1:5722 METRO WAY SW STE B
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9524
Practice Address - Country:US
Practice Address - Phone:616-840-7529
Practice Address - Fax:616-840-9693
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist