Healthcare Provider Details

I. General information

NPI: 1104721463
Provider Name (Legal Business Name): JENNIFER BROWNING HAFNER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 PETTIS RD
WEST HAVEN VT
05743-8901
US

IV. Provider business mailing address

113 PETTIS RD
WEST HAVEN VT
05743-8901
US

V. Phone/Fax

Practice location:
  • Phone: 845-216-0560
  • Fax:
Mailing address:
  • Phone: 845-216-0560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number073.0900340
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: