Healthcare Provider Details

I. General information

NPI: 1154225621
Provider Name (Legal Business Name): MARY ELIZABETH JACKSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PARK AVE
SOUTH POINT OH
45680-9622
US

IV. Provider business mailing address

430 CARDINAL RD
RUSSELL KY
41169-1512
US

V. Phone/Fax

Practice location:
  • Phone: 740-377-2756
  • Fax:
Mailing address:
  • Phone: 740-550-2383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA002554
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: