Individual
GWENNETTA PATRICE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
700 DAVEGA DR, LEXINGTON, SC 29073-9698
(803) 796-8731
Mailing address
700 DAVEGA DR, LEXINGTON, SC 29073-9698
(803) 796-8731
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
4800
SC
Other
Enumeration date
12/31/2018
Last updated
12/31/2018
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