Healthcare Provider Details

I. General information

NPI: 1568309664
Provider Name (Legal Business Name): JENNIFER ANN JACKSON COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S 9TH ST
MIDLOTHIAN TX
76065-3836
US

IV. Provider business mailing address

910 S 9TH ST
MIDLOTHIAN TX
76065-3836
US

V. Phone/Fax

Practice location:
  • Phone: 469-410-3566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number209412
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: