=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922413228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONICA JACKMAN OTR/L, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2014
-----------------------------------------------------
Last Update Date | 06/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 SW DARWIN BLVD STE 101B
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953-3365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-283-2484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3242 SW FILLMORE ST
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953-3480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-283-2484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST, OWNER
-----------------------------------------------------
Name | DR. MONICA MOORE JACKMAN
-----------------------------------------------------
Credential | OTD, OTR/L
-----------------------------------------------------
Telephone | 352-283-2484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT9381
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------