Healthcare Provider Details

I. General information

NPI: 1578724167
Provider Name (Legal Business Name): JENNIFER WALKER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 E 175TH ST
CLEVELAND OH
44128-2223
US

IV. Provider business mailing address

4109 E 175TH ST
CLEVELAND OH
44128-2223
US

V. Phone/Fax

Practice location:
  • Phone: 216-410-5512
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA-07158
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: