Provider Demographics
NPI:1245297381
Name:JACKSON, CHRISTIE LYNN (OTR)
Entity type:Individual
Prefix:MRS
First Name:CHRISTIE
Middle Name:LYNN
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:PO BOX 55270
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-5270
Mailing Address - Country:US
Mailing Address - Phone:501-604-4170
Mailing Address - Fax:501-604-3223
Practice Address - Street 1:9709 WILD MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-4366
Practice Address - Country:US
Practice Address - Phone:501-690-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1998225X00000X
AROTR1998225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157430721Medicaid