MEDICARE: JACKIE MARIE SIDES OTR/L, CHT

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	225XH1200X	Hand Occupational Therapist	0119003320	VA

General Provider Information

NPI Number	:	1659085207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE MARIE SIDES OTR/L, CHT

Provider Business Mailing Address
First Line	:	2050 POINTER RD
Second Line	:
City	:	ALTON
State	:	VA
Zip	:	24520-3508
Country	:	US
Telephone Number	:	757-448-5674
Fax Number	:

Provider Business Practice Location Address
First Line	:	4819 RIVERSIDE DR STE C
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24541-5581
Country	:	US
Telephone Number	:	434-421-6179
Fax Number	:

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

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	03/26/2026

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