MEDICARE: JEREMY ALLE WILLIAMS 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	14227	FL

General Provider Information

NPI Number	:	1467813089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY ALLE WILLIAMS COTA/L

Provider Business Mailing Address
First Line	:	9624 BAYVIEW AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-1544
Country	:	US
Telephone Number	:	904-521-9302
Fax Number	:

Provider Business Practice Location Address
First Line	:	9624 BAYVIEW AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-1544
Country	:	US
Telephone Number	:	904-521-9302
Fax Number	:

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

Provider Enumeration Date	:	03/09/2016
Last Update Date	:	03/09/2016

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