Healthcare Provider Details

I. General information

NPI: 1396481081
Provider Name (Legal Business Name): CATHERINE GRACE JEZEK COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2552 E KENOSHA ST
BROKEN ARROW OK
74014-6712
US

IV. Provider business mailing address

2012 E PRINCETON ST
BROKEN ARROW OK
74012-2095
US

V. Phone/Fax

Practice location:
  • Phone: 918-893-3735
  • Fax:
Mailing address:
  • Phone: 405-306-9507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2399
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: