Healthcare Provider Details

I. General information

NPI: 1518099191
Provider Name (Legal Business Name): ARTIMEASE JACKSON MBA,OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. ARTIMEASE JACKSON WASHINGTON

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 CRESTWOOD CT
LITHONIA GA
30058-5996
US

IV. Provider business mailing address

504 CRESTWOOD CT
LITHONIA GA
30058-5996
US

V. Phone/Fax

Practice location:
  • Phone: 770-498-4095
  • Fax:
Mailing address:
  • Phone: 770-498-4095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number000961
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: