Healthcare Provider Details

I. General information

NPI: 1902144058
Provider Name (Legal Business Name): JILL J BROYLES COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2013
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 PARKCLIFF DR
HOLIDAY ISLAND AR
72631-8045
US

IV. Provider business mailing address

25061 FAT BOB TRL
SHELL KNOB MO
65747-7889
US

V. Phone/Fax

Practice location:
  • Phone: 479-363-6422
  • Fax: 479-363-6763
Mailing address:
  • Phone: 316-204-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2021006128
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1800833
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number3786
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1905
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: