Healthcare Provider Details

I. General information

NPI: 1881177863
Provider Name (Legal Business Name): JENNIFER LEA SHORT COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S MAIN ST
BROKEN ARROW OK
74012-5528
US

IV. Provider business mailing address

2114 W WALNUT ST
COLLINSVILLE OK
74021-1708
US

V. Phone/Fax

Practice location:
  • Phone: 918-845-8641
  • Fax:
Mailing address:
  • Phone: 918-845-8641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1419
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: