=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659769628
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JO LEE ERICKSON OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2014
-----------------------------------------------------
Last Update Date | 07/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1127 HIGHWAY 71 S
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-584-8064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 911 PORT ARTHUR AVE
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-584-8064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OTR2783
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 2783
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------