Provider Demographics
NPI:1043749302
Name:LAWRENCE, JACOB STEPHEN (COTA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:STEPHEN
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 W HARTFORD DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-1820
Mailing Address - Country:US
Mailing Address - Phone:480-544-8751
Mailing Address - Fax:
Practice Address - Street 1:3116 W. HARTFORD DR.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053
Practice Address - Country:US
Practice Address - Phone:480-544-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6921224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant