Healthcare Provider Details

I. General information

NPI: 1578253373
Provider Name (Legal Business Name): JENNIFER PARKER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 WALLER RD # 200
RICHMOND VA
23230-2912
US

IV. Provider business mailing address

7404 PENNBROOK CT
CHESTERFIELD VA
23832-8276
US

V. Phone/Fax

Practice location:
  • Phone: 804-893-5010
  • Fax: 804-412-8105
Mailing address:
  • Phone: 801-949-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131002797
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: