Healthcare Provider Details

I. General information

NPI: 1144043308
Provider Name (Legal Business Name): JENNY SUE BROWN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/06/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 S FITNESS PL
EAGLE ID
83616-6828
US

IV. Provider business mailing address

5940 W PORT LN APT 103
BOISE ID
83703-4892
US

V. Phone/Fax

Practice location:
  • Phone: 208-957-6301
  • Fax:
Mailing address:
  • Phone: 208-317-6268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA-2976
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: