Healthcare Provider Details

I. General information

NPI: 1124306527
Provider Name (Legal Business Name): JACQUELYN JOY JOHNSON COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W 36TH ST
SCOTTSBLUFF NE
69361-4636
US

IV. Provider business mailing address

2018 5TH AVE
SCOTTSBLUFF NE
69361-2044
US

V. Phone/Fax

Practice location:
  • Phone: 308-635-2019
  • Fax:
Mailing address:
  • Phone: 308-220-4573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number747
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: