Healthcare Provider Details

I. General information

NPI: 1659559508
Provider Name (Legal Business Name): JENNIFER MIX COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2008
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 W LAKE AVE SUITE 200
GLENVIEW IL
60026-1223
US

IV. Provider business mailing address

4517 ROSLYN RD
DOWNERS GROVE IL
60515-5803
US

V. Phone/Fax

Practice location:
  • Phone: 847-998-1188
  • Fax:
Mailing address:
  • Phone: 708-670-8432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.002462
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: