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General NPI Number Information
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NPI Number | 1497887202
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Entity Type | Individual
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Provider Name | JENNIFER SUE FAUST COTA
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Gender | Female
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Dates
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Enumeration Date | 03/09/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 463 S ROOSEVELT ROAD O
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City | PORTALES
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State | NM
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Zip | 88130-9676
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Country | US
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Telephone | 505-760-6691
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Fax |
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Provider Business Mailing Address
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Address Line | 463 S ROOSEVELT ROAD O
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City | PORTALES
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State | NM
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Zip | 88130-9676
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Country | US
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Telephone |
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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 | 1581
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License Number State | NM
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