Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XH1200X | Occupational Therapist - Hand | 105104 | TX |
NPI | 1245520808 |
---|---|
Provider Name | Rod Dewey Jackson |
First Address | Dallas, TX 75246-1713 |
Second Address | Dallas, TX 75246-1713 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2011 |
Last Update Date | 15/04/2011 |