Individual
MRS. CHANTE OLIVIA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
C.O.T.A.L
Contact information
Practice address
16112 MOUNT VERNON ST, SOUTHFIELD, MI 48075-3188
(313) 617-8398
Mailing address
25330 W 6 MILE RD, REDFORD, MI 48240-2105
(313) 531-6874
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
5202006981
MI
225X00000X
Occupational Therapist
5202006981
MI
Other
Enumeration date
12/18/2023
Last updated
12/18/2023
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