Individual
MISS TYWANNA LASHEA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
2237 ENGLE RD, FORT WAYNE, IN 46809-1404
(260) 747-2353
Mailing address
PO BOX 11532, FORT WAYNE, IN 46859-1532
(260) 348-0124
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
32001156A
IN
Other
Enumeration date
03/27/2007
Last updated
07/08/2007
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