MEDICARE: JENNIFER LEIGHT BOLAM 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	0131000679	VA

General Provider Information

NPI Number	:	1295038347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LEIGHT BOLAM COTA/L

Provider Business Mailing Address
First Line	:	915 GLYNN SPRINGS DR
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-2832
Country	:	US
Telephone Number	:	757-206-6347
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 GLYNN SPRINGS DR
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-2832
Country	:	US
Telephone Number	:	757-206-6347
Fax Number	:

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

Provider Enumeration Date	:	12/13/2010
Last Update Date	:	12/13/2010

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