Healthcare Provider Details

I. General information

NPI: 1689910663
Provider Name (Legal Business Name): JENNIFER MARIE POLLY COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2012
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 OLD BRUCEVILLE RD
VINCENNES IN
47591-3889
US

IV. Provider business mailing address

3801 OLD BRUCEVILLE RD
VINCENNES IN
47591-3889
US

V. Phone/Fax

Practice location:
  • Phone: 812-886-4677
  • Fax: 812-886-4678
Mailing address:
  • Phone: 812-886-4677
  • Fax: 812-886-4678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32002226A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: