Healthcare Provider Details

I. General information

NPI: 1851459770
Provider Name (Legal Business Name): NACOLE MARIE JACKSON COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S CALUMET RD SUITE 3
CHESTERTON IN
46304-3285
US

IV. Provider business mailing address

418 PLANETT ST
LA PORTE IN
46350-2682
US

V. Phone/Fax

Practice location:
  • Phone: 219-983-9675
  • Fax:
Mailing address:
  • Phone: 219-325-3541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001281A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: