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General NPI Number Information
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NPI Number | 1356777411
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Entity Type | Individual
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Provider Name | JACKIE D NICKSON OTD, OTR/L
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Gender | Female
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Dates
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Enumeration Date | 09/20/2013
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Last Update Date | 01/12/2014
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Provider Practice Location Address
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Address Line | 6664 SINCLAIR DR
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City | HORN LAKE
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State | MS
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Zip | 38637-2598
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Country | US
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Telephone | 901-230-4982
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Fax | 662-393-2673
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Provider Business Mailing Address
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Address Line | 6664 SINCLAIR DR
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City | HORN LAKE
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State | MS
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Zip | 38637-2598
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Country | US
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Telephone | 901-230-4982
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Fax | 662-393-2673
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT1986
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 1986
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State | MS
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Taxonomy #4
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State | MS
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Taxonomy #5
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number |
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License Number State | MS
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Taxonomy #6
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State | MS
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