Healthcare Provider Details

I. General information

NPI: 1609608942
Provider Name (Legal Business Name): JARED WYRICK COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 E LINCOLN AVE
SEARCY AR
72143-7402
US

IV. Provider business mailing address

130 UNDERHILL RD
BEEBE AR
72012-9751
US

V. Phone/Fax

Practice location:
  • Phone: 501-230-3100
  • Fax: 501-882-9825
Mailing address:
  • Phone: 501-230-3100
  • Fax: 501-882-9825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A2050
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: