Healthcare Provider Details

I. General information

NPI: 1619731452
Provider Name (Legal Business Name): JENNIFER J MCCOURT COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 BENITA DR # 3818470
MINGO JCT OH
43938-1329
US

IV. Provider business mailing address

121 PARK ST
MINGO JUNCTION OH
43938-1128
US

V. Phone/Fax

Practice location:
  • Phone: 740-381-8470
  • Fax:
Mailing address:
  • Phone: 740-381-3278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA01606
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: