=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346439601
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAN L. GILES OTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2007
-----------------------------------------------------
Last Update Date | 10/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 MURCHISON ST
-----------------------------------------------------
City | FRANKSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75763-9721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-876-7387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15001 STATE HIGHWAY 19 S
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75751-6564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-253-2469
-----------------------------------------------------
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 | 208484
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------