Healthcare Provider Details

I. General information

NPI: 1861693970
Provider Name (Legal Business Name): JENNIFER MAISANO COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 S 4TH ST
PHILADELPHIA PA
19148-4712
US

IV. Provider business mailing address

412 S ELMWOOD AVE
GLENOLDEN PA
19036-2327
US

V. Phone/Fax

Practice location:
  • Phone: 215-271-1080
  • Fax:
Mailing address:
  • Phone: 610-583-2977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP003537L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: