Healthcare Provider Details

I. General information

NPI: 1609237585
Provider Name (Legal Business Name): JEFFREY TAYLOR COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W HOMER ST
MICHIGAN CITY IN
46360-4358
US

IV. Provider business mailing address

8259 WICKER AVE
SAINT JOHN IN
46373-8878
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-8511
  • Fax:
Mailing address:
  • Phone: 219-365-6560
  • Fax: 219-365-6561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32000843A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: