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General NPI Number Information
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NPI Number | 1659085207
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Entity Type | Individual
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Provider Name | JACKIE MARIE SIDES OTR/L, CHT
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Gender | Female
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Dates
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Enumeration Date | 01/09/2023
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Last Update Date | 01/09/2023
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Provider Practice Location Address
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Address Line | 165 HOLT GARRISON PKWY STE 595-A
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City | DANVILLE
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State | VA
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Zip | 24540-5949
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Country | US
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Telephone | 434-688-0163
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Fax |
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Provider Business Mailing Address
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Address Line | 2050 POINTER RD
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City | ALTON
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State | VA
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Zip | 24520-3508
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Country | US
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Telephone | 757-448-5674
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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 | 225XH1200X
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Taxonomy Name | Hand Occupational Therapist
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License Number | 0119003320
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License Number State | VA
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