Healthcare Provider Details

I. General information

NPI: 1538383419
Provider Name (Legal Business Name): SALLY JACKSON O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 STILESBORO RD NW SUITE 430
KENNESAW GA
30152-7744
US

IV. Provider business mailing address

5150 STILESBORO RD NW SUITE 430
KENNESAW GA
30152-7744
US

V. Phone/Fax

Practice location:
  • Phone: 770-630-0053
  • Fax: 770-218-2201
Mailing address:
  • Phone: 770-630-0053
  • Fax: 770-218-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT001398
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: