Healthcare Provider Details

I. General information

NPI: 1518787324
Provider Name (Legal Business Name): JENNIFER LEIGH VAUGHN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 W CHESTNUT ST
KAHOKA MO
63445-1314
US

IV. Provider business mailing address

511 W LAFAYETTE ST
PALMYRA MO
63461-1481
US

V. Phone/Fax

Practice location:
  • Phone: 660-727-2377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057004582
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: