MEDICARE: JAMIE ANN THAXTON COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	7421723-4202	UT

General Provider Information

NPI Number	:	1245593185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE ANN THAXTON COTA/L

Provider Business Mailing Address
First Line	:	1780 KEYSVIEW CT APT 12
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-8049
Country	:	US
Telephone Number	:	801-671-2787
Fax Number	:

Provider Business Practice Location Address
First Line	:	1780 KEYSVIEW CT APT 12
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-8049
Country	:	US
Telephone Number	:	801-671-2787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2012
Last Update Date	:	06/15/2012

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