Healthcare Provider Details

I. General information

NPI: 1992263800
Provider Name (Legal Business Name): JESSICA ESTRIDGE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2019
Last Update Date: 03/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8274 E SAN RD
SOUTH RANGE WI
54874-8621
US

IV. Provider business mailing address

33324 STATE ROAD 35
DANBURY WI
54830-9459
US

V. Phone/Fax

Practice location:
  • Phone: 715-398-3523
  • Fax:
Mailing address:
  • Phone: 651-269-8415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5215
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: