Healthcare Provider Details

I. General information

NPI: 1821915570
Provider Name (Legal Business Name): JESSICA COMBS COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 CRAIGHOLM CT
CHARLOTTE NC
28262-2574
US

IV. Provider business mailing address

3624 CRAIGHOLM CT
CHARLOTTE NC
28262-2574
US

V. Phone/Fax

Practice location:
  • Phone: 317-796-6911
  • Fax:
Mailing address:
  • Phone: 317-796-6911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number16978
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: