MEDICARE: SHERELLE NICOLE JACKSON OTD, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	2025051197	MO

General Provider Information

NPI Number	:	1154285666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERELLE NICOLE JACKSON OTD, OTR/L

Provider Business Mailing Address
First Line	:	452 NW LEGACY DR
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-2894
Country	:	US
Telephone Number	:
Fax Number	:	816-436-8143

Provider Business Practice Location Address
First Line	:	452 NW LEGACY DR
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-2894
Country	:	US
Telephone Number	:	816-436-6383
Fax Number	:	816-436-8143

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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Directions to “ SHERELLE NICOLE JACKSON OTD, OTR/L” Practice Location

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