Healthcare Provider Details

I. General information

NPI: 1336503150
Provider Name (Legal Business Name): JENNIFER NICHOLE DENNISON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 HIGH BLUFF DR STE 100
SAN DIEGO CA
92130-3077
US

IV. Provider business mailing address

12400 HIGH BLUFF DR STE 100
SAN DIEGO CA
92130-3077
US

V. Phone/Fax

Practice location:
  • Phone: 866-480-3874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOTP-OTA-LIC4075
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: