Healthcare Provider Details

I. General information

NPI: 1336159094
Provider Name (Legal Business Name): JENNIFER BROOK DICKSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1000 S FORT THOMAS AVE
FORT THOMAS KY
41075-2305
US

IV. Provider business mailing address

2918 CLERMONT FARMS RD
BETHEL OH
45106-7813
US

V. Phone/Fax

Practice location:
  • Phone: 513-861-3100
  • Fax:
Mailing address:
  • Phone: 513-861-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA. 03412
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: