Healthcare Provider Details

I. General information

NPI: 1407190895
Provider Name (Legal Business Name): JACQUELINE LYN ASHLOCK COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11527 W PEORIA AVE
YOUNGTOWN AZ
85363-1640
US

IV. Provider business mailing address

11527 W PEORIA AVE
YOUNGTOWN AZ
85363-1640
US

V. Phone/Fax

Practice location:
  • Phone: 623-933-4683
  • Fax: 623-972-4993
Mailing address:
  • Phone: 623-933-4683
  • Fax: 623-972-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1549
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: