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General NPI Number Information
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NPI Number | 1841782398
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Entity Type | Individual
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Provider Name | CHRYSTAL MAE JACKSON COTA
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Gender | Female
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Dates
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Enumeration Date | 05/31/2018
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Last Update Date | 05/31/2018
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Provider Practice Location Address
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Address Line | 5417 ALTAMESA BLVD
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City | FORT WORTH
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State | TX
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Zip | 76123-2804
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Country | US
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Telephone | 866-980-2475
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Fax |
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Provider Business Mailing Address
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Address Line | 640 BENT OAK DR
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City | FORT WORTH
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State | TX
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Zip | 76131-4230
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Country | US
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Telephone | 806-433-8191
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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 | 210256
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License Number State | TX
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