MEDICARE: JACQUELYNN SKAARUP COTA

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	OT-A1107	AR

General Provider Information

NPI Number	:	1356894828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYNN SKAARUP COTA

Provider Business Mailing Address
First Line	:	5415 EMERALD PARK BLVD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-4520
Country	:	US
Telephone Number	:	253-861-3349
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 PARK DR
Second Line	:	SUITE A
City	:	HOLIDAY ISLAND
State	:	AR
Zip	:	72631-9216
Country	:	US
Telephone Number	:	479-363-6422
Fax Number	:	479-363-6763

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

Provider Enumeration Date	:	08/01/2016
Last Update Date	:	08/01/2016

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