Healthcare Provider Details

I. General information

NPI: 1386563906
Provider Name (Legal Business Name): JACLYN M GUTIERREZ COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 PASEO VERDE PKWY STE 155
HENDERSON NV
89074-7120
US

IV. Provider business mailing address

2785 AUDRA FAYE AVE
HENDERSON NV
89052-5002
US

V. Phone/Fax

Practice location:
  • Phone: 702-515-4009
  • Fax:
Mailing address:
  • Phone: 702-862-9886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number10-1028
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: