Provider Demographics
NPI:1700812567
Name:JACKSON, SHELIA (OT)
Entity type:Individual
Prefix:
First Name:SHELIA
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 1:1908 FLINT RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-6031
Mailing Address - Country:US
Mailing Address - Phone:256-340-9708
Mailing Address - Fax:256-340-9624
Practice Address - Street 1:2250 US HIGHWAY 43 STE 107
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:AL
Practice Address - Zip Code:35594-8622
Practice Address - Country:US
Practice Address - Phone:205-487-0540
Practice Address - Fax:205-487-0569
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1003819608OtherGROUP NPI
AL529917620Medicaid
AL529917620Medicaid