Provider Demographics
NPI:1003045642
Name:FOOTE, JACQUELINE (COTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FOOTE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W LEE ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:MO
Mailing Address - Zip Code:64730-1130
Mailing Address - Country:US
Mailing Address - Phone:660-227-9007
Mailing Address - Fax:
Practice Address - Street 1:202 E MILL ST
Practice Address - Street 2:
Practice Address - City:HUMANSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65674-8507
Practice Address - Country:US
Practice Address - Phone:417-754-1601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-03
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003149224Z00000X
CA1517224Z00000X
TX210437224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant