Healthcare Provider Details

I. General information

NPI: 1205272218
Provider Name (Legal Business Name): JAYMELYN HANSEN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 BOYDTON PLANK RD
NORTH DINWIDDIE VA
23803-7401
US

IV. Provider business mailing address

16603 COX RD
CHURCH ROAD VA
23833-3049
US

V. Phone/Fax

Practice location:
  • Phone: 804-861-1324
  • Fax:
Mailing address:
  • Phone: 804-691-4518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000789
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: