=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265325302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER M CANCHOLA COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2025
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38257 MOUND RD STE 200
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310-3466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-722-7524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50928 DARTMOOR DR
-----------------------------------------------------
City | SHELBY TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48317-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-360-5135
-----------------------------------------------------
Fax | 586-360-5135
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 5202008007
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------