MEDICARE: JAYMELYN HANSEN COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	0131000789	VA

General Provider Information

NPI Number	:	1205272218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAYMELYN HANSEN COTA/L

Provider Business Mailing Address
First Line	:	16603 COX RD
Second Line	:
City	:	CHURCH ROAD
State	:	VA
Zip	:	23833-3049
Country	:	US
Telephone Number	:	804-691-4518
Fax Number	:

Provider Business Practice Location Address
First Line	:	6405 BOYDTON PLANK RD
Second Line	:
City	:	NORTH DINWIDDIE
State	:	VA
Zip	:	23803-7401
Country	:	US
Telephone Number	:	804-861-1324
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2013
Last Update Date	:	05/16/2013

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