Provider Demographics
NPI:1144962077
Name:JACKSON, JULIE MARIE (OTR)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 CAMILLE DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-1444
Mailing Address - Country:US
Mailing Address - Phone:903-932-0467
Mailing Address - Fax:
Practice Address - Street 1:107 BELLA MONTAGNA CIR
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-2648
Practice Address - Country:US
Practice Address - Phone:512-598-0714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist