Healthcare Provider Details

I. General information

NPI: 1558908665
Provider Name (Legal Business Name): JENNIFER GOODING COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1849 CAPRI DR
CHARLESTON SC
29407-7603
US

IV. Provider business mailing address

448 SANDERS FARM LN
CHARLESTON SC
29492-7710
US

V. Phone/Fax

Practice location:
  • Phone: 843-270-8505
  • Fax:
Mailing address:
  • Phone: 843-303-5572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5310
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: