Healthcare Provider Details

I. General information

NPI: 1275655482
Provider Name (Legal Business Name): DOUGLENE J JACKSON PHD, OTR/L, LMT, ATP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 NW 207TH WAY
PEMBROKE PINES FL
33029-3509
US

IV. Provider business mailing address

240 NW 207TH WAY
PEMBROKE PINES FL
33029-3509
US

V. Phone/Fax

Practice location:
  • Phone: 678-472-3201
  • Fax:
Mailing address:
  • Phone: 678-472-3201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA29727
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT003627
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT10451
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: