Healthcare Provider Details

I. General information

NPI: 1477714301
Provider Name (Legal Business Name): JENNIFER STEPHANIE MCCAULEY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10631 S 51ST ST STE 1
PHOENIX AZ
85044-5225
US

IV. Provider business mailing address

PO BOX 50218
PHOENIX AZ
85076-0218
US

V. Phone/Fax

Practice location:
  • Phone: 480-398-4280
  • Fax: 480-398-4281
Mailing address:
  • Phone: 480-398-4280
  • Fax: 480-398-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA-047020
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00024812
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: