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General NPI Number Information
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NPI Number | 1871173898
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Entity Type | Individual
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Provider Name | JENNIFER ROBERTSONJ COTA/L
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Gender | Female
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Dates
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Enumeration Date | 04/13/2021
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Last Update Date | 04/13/2021
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Provider Practice Location Address
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Address Line | 403 WATERCRESS DR
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City | VAN BUREN
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State | MO
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Zip | 63965-6301
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Country | US
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Telephone | 573-323-4282
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Fax |
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Provider Business Mailing Address
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Address Line | 261 CARTER 223
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City | ELLSINORE
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State | MO
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Zip | 63937-8673
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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 | 004349
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License Number State | MO
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