Active NPI
Gwennetta Patrice Jackson, COTA
- Occupational Therapy Assistant
- Lexington, SC
National Provider Identifier
1316419443
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapy Assistant
- License
- 4800
- Practice address
- 700 Davega Dr
Lexington, SC 29073-9698 - Phone
- (803) 796-8731
- NPI assigned
- Dec 31, 2018
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapy Assistant | 224Z00000X | 4800 | SC | Primary |
Addresses
Primary practice location
700 Davega Dr
Lexington, SC 29073-9698
Mailing address
700 Davega Dr
Lexington, SC 29073-9698
Phone (803) 796-8731
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4800 | SC | MD | Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1546214400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1546214400000",
"number": "1316419443",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "700 DAVEGA DR",
"city": "LEXINGTON",
"state": "SC",
"postal_code": "290739698",
"telephone_number": "803-796-8731"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "700 DAVEGA DR",
"city": "LEXINGTON",
"state": "SC",
"postal_code": "290739698",
"telephone_number": "803-796-8731"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "GWENNETTA",
"middle_name": "PATRICE",
"credential": "COTA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2018-12-31",
"last_updated": "2018-12-31",
"status": "A"
},
"taxonomies": [
{
"code": "224Z00000X",
"taxonomy_group": "",
"desc": "Occupational Therapy Assistant",
"state": "SC",
"license": "4800",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lexington, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 31, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.