Provider Demographics
NPI:1164805032
Name:JOHN, JENNIFER L (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:JOHN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:GOODLUCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:418 REGULATORS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-2085
Mailing Address - Country:US
Mailing Address - Phone:919-245-0316
Mailing Address - Fax:
Practice Address - Street 1:2626 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-1043
Practice Address - Country:US
Practice Address - Phone:877-781-9565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7120224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant