Basic Information
| Provider Information | |||||||||
| NPI: | 1972778181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DEBBRA | ||||||||
| MiddleName: | CARLINE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3703 W LAKE AVE | ||||||||
| Address2: | SUITE,200 | ||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600265823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479981188 | ||||||||
| FaxNumber: | 8478322103 | ||||||||
| Practice Location | |||||||||
| Address1: | 3703 W LAKE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600265823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479981188 | ||||||||
| FaxNumber: | 8479988008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 057000216 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.