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General NPI Number Information
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NPI Number | 1508984816
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Entity Type | Individual
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Provider Name | ALEXIS MALAINA JACKSON OTR L
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Gender | Female
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1800 NATIONS DR SUITE 208
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City | GURNEE
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State | IL
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Zip | 60031-9168
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Country | US
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Telephone | 847-477-9034
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Fax |
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Provider Business Mailing Address
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Address Line | 820 KINGSTON AVE
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City | RACINE
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State | WI
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Zip | 53402-4049
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Country | US
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Telephone |
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Fax |
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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 | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State | IL
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