Healthcare Provider Details

I. General information

NPI: 1538436944
Provider Name (Legal Business Name): JENNIFER LYNN GRAICHEN-HUETTL COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S 9TH ST
DE PERE WI
54115-1393
US

IV. Provider business mailing address

N2283 HEAVENLY DR
GREENVILLE WI
54942-9790
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-4145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1432-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: