Healthcare Provider Details

I. General information

NPI: 1699432310
Provider Name (Legal Business Name): JESSICA CARNEY COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14820 E 42ND ST S
INDEPENDENCE MO
64055-4775
US

IV. Provider business mailing address

710 GOLF ST
ODESSA MO
64076-1468
US

V. Phone/Fax

Practice location:
  • Phone: 816-695-1255
  • Fax:
Mailing address:
  • Phone: 816-565-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2021043580
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: