MEDICARE: MR. RODNEY JACKSON

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

General Provider Information

NPI Number	:	1205125747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RODNEY JACKSON

Provider Business Mailing Address
First Line	:	18135 W CATAWBA AVE STE 11
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-5641
Country	:	US
Telephone Number	:	704-780-3110
Fax Number	:

Provider Business Practice Location Address
First Line	:	18135 W CATAWBA AVE STE 11
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-5641
Country	:	US
Telephone Number	:	704-780-3110
Fax Number	:

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

Provider Enumeration Date	:	04/05/2011
Last Update Date	:	04/05/2011

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Directions to “ MR. RODNEY JACKSON ” Practice Location

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