MEDICARE: MS. JEAN ANNETTE GOFORTH 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	OTA 1509	CA

General Provider Information

NPI Number	:	1568595031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEAN ANNETTE GOFORTH COTA

Provider Business Mailing Address
First Line	:	6177 GREENHAVEN DR APT A
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95831-1652
Country	:	US
Telephone Number	:	530-329-6854
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 ELVAS AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95819-2250
Country	:	US
Telephone Number	:	916-454-4700
Fax Number	:

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

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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