Healthcare Provider Details

I. General information

NPI: 1992095152
Provider Name (Legal Business Name): JENNIFER ELEANOR KOFFMAN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N HILLTOP DRIVE
TITUSVILLE FL
32796
US

IV. Provider business mailing address

140 N HILLTOP DRIVE
TITUSVILLE FL
32796
US

V. Phone/Fax

Practice location:
  • Phone: 321-225-9540
  • Fax:
Mailing address:
  • Phone: 321-225-9540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number10448
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: