Chrystal Mae Jackson, COTA

Primary specialty

Occupational Therapy AssistantTaxonomy code 224Z00000X

License

210256 Issued in TX

Practice address

5417 Altamesa Blvd
Fort Worth, TX 76123-2804

Phone

(866) 980-2475

NPI assigned

May 31, 2018

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Mrs. Chrystal Mae Wolven Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1527724800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1527724800000",
    "number": "1841782398",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "640 BENT OAK DR",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761314230",
            "telephone_number": "806-433-8191"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5417 ALTAMESA BLVD",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761232804",
            "telephone_number": "866-980-2475"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "CHRYSTAL",
        "middle_name": "MAE",
        "name_prefix": "Mrs.",
        "credential": "COTA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2018-05-31",
        "last_updated": "2018-05-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "224Z00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapy Assistant",
            "state": "TX",
            "license": "210256",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "CHRYSTAL",
            "last_name": "WOLVEN",
            "middle_name": "MAE",
            "prefix": "MRS.",
            "credential": "COTA",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Ahrielle Jackson
• Alysa Michele Jackson, MSW
• Ashli Brooke Jackson, RN
• Bree Jackson, BCBA
• Charles Jackson
• Clayton Ralph Jackson, MD
• D'Nika Jackson
• Illya Jackson
• John S Jackson, M.D.
• Julie Jackson, RPH

• Occupational Therapy Assistant in Fort Worth, TX
• Providers in Fort Worth, TX by specialty
• Occupational Therapy Assistant in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 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.

Verify at the official NPI Registry.