MEDICARE: JENNIFER GOODING 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	106S00000X	Behavior Technician
2	224Z00000X	Occupational Therapy Assistant	5310	SC

General Provider Information

NPI Number	:	1558908665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER GOODING COTA/L

Provider Business Mailing Address
First Line	:	448 SANDERS FARM LN
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29492-7710
Country	:	US
Telephone Number	:	843-303-5572
Fax Number	:

Provider Business Practice Location Address
First Line	:	1849 CAPRI DR
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-7603
Country	:	US
Telephone Number	:	843-270-8505
Fax Number	:

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

Provider Enumeration Date	:	12/09/2019
Last Update Date	:	09/20/2021

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Directions to “ JENNIFER GOODING COTA/L” Practice Location

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