Provider Demographics
NPI:1164794897
Name:DAVIS, JEANINE PATRICIA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:PATRICIA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:JEANINE
Other - Middle Name:PATRICIA
Other - Last Name:PORTLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:5299 LYNDELL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-1847
Mailing Address - Country:US
Mailing Address - Phone:219-763-6504
Mailing Address - Fax:
Practice Address - Street 1:2350 TAFT ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46404-3349
Practice Address - Country:US
Practice Address - Phone:219-977-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000437A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant