Healthcare Provider Details

I. General information

NPI: 1215287008
Provider Name (Legal Business Name): LIBERTY ZARIAH JACKSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 FALK RD
VANCOUVER WA
98661-6392
US

IV. Provider business mailing address

5718 SW SHATTUCK RD
PORTLAND OR
97221-1038
US

V. Phone/Fax

Practice location:
  • Phone: 360-313-1250
  • Fax:
Mailing address:
  • Phone: 503-704-7967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT60234654
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT287043
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: