Provider Demographics
NPI:1487877387
Name:JACKSON, SHARON K (OTR)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9335 RIGGS ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-1107
Mailing Address - Country:US
Mailing Address - Phone:409-860-1843
Mailing Address - Fax:
Practice Address - Street 1:9335 RIGGS ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-1107
Practice Address - Country:US
Practice Address - Phone:409-860-1843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102620225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110025701Medicaid
TX8T2057OtherINSURANCE