Healthcare Provider Details

I. General information

NPI: 1396382610
Provider Name (Legal Business Name): JASON PACK COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9022 RICHFIELD LN
KNOXVILLE TN
37924-4579
US

IV. Provider business mailing address

9022 RICHFIELD LN
KNOXVILLE TN
37924-4579
US

V. Phone/Fax

Practice location:
  • Phone: 865-279-6718
  • Fax: 855-232-8604
Mailing address:
  • Phone: 865-293-9449
  • Fax: 855-232-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2473
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: