Provider Demographics
NPI:1053892604
Name:JACKSON, TASHATA RE'KAL (COTA)
Entity type:Individual
Prefix:
First Name:TASHATA
Middle Name:RE'KAL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:TASHATA
Other - Middle Name:RE'KAL
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:6860 DALLAS PKWY STE 550
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-4252
Mailing Address - Country:US
Mailing Address - Phone:903-984-3511
Mailing Address - Fax:
Practice Address - Street 1:2700 S HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-4033
Practice Address - Country:US
Practice Address - Phone:903-984-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212080224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant