Provider Demographics
NPI:1538383419
Name:JACKSON, SALLY (OT)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 STILESBORO RD NW
Mailing Address - Street 2:SUITE 430
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7744
Mailing Address - Country:US
Mailing Address - Phone:770-630-0053
Mailing Address - Fax:770-218-2201
Practice Address - Street 1:5150 STILESBORO RD NW
Practice Address - Street 2:SUITE 430
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7744
Practice Address - Country:US
Practice Address - Phone:770-630-0053
Practice Address - Fax:770-218-2201
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001398225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000611289CMedicaid