Healthcare Provider Details

I. General information

NPI: 1306446562
Provider Name (Legal Business Name): JESSICA BASKIN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 COUNTRY DR
FREMONT CA
94536-5356
US

IV. Provider business mailing address

395 ANO NUEVO AVE APT 604
SUNNYVALE CA
94085-1620
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-4242
  • Fax:
Mailing address:
  • Phone: 916-402-7283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: