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General NPI Number Information
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NPI Number | 1205116589
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Entity Type | Individual
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Provider Name | JACQUELINE RENEE HARRIS COTA/L
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Gender | Female
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Dates
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Enumeration Date | 08/18/2011
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Last Update Date | 08/18/2011
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Provider Practice Location Address
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Address Line | 7887 N 16TH ST UNIT #125
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City | PHOENIX
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State | AZ
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Zip | 85020-4417
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Country | US
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Telephone | 419-908-0892
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Fax |
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Provider Business Mailing Address
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Address Line | 7887 N 16TH ST UNIT #125
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City | PHOENIX
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State | AZ
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Zip | 85020-4417
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Country | US
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Telephone | 419-908-0892
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 4860
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 04337
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 52020007306
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License Number State | MI
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