=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275363152
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE AYERS COTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2024
-----------------------------------------------------
Last Update Date | 08/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3392 MOTOR AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034-3712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-742-2230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1927 N EDISON BLVD
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-669-9139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 4575
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------