Provider Demographics
NPI:1730814724
Name:ANACKER, JADE MORGAN (COTA/L)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:MORGAN
Last Name:ANACKER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14550 SW 29TH PL
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-1003
Mailing Address - Country:US
Mailing Address - Phone:954-661-1774
Mailing Address - Fax:
Practice Address - Street 1:12966 SW 89TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-5850
Practice Address - Country:US
Practice Address - Phone:786-554-8920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17536224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant