Provider Demographics
NPI:1225710189
Name:REDICK, JACQUELINE JEAN (COTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JEAN
Last Name:REDICK
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 1:4159 S DEWITT RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9208
Mailing Address - Country:US
Mailing Address - Phone:616-405-3071
Mailing Address - Fax:
Practice Address - Street 1:4159 S DEWITT RD
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-9208
Practice Address - Country:US
Practice Address - Phone:616-405-3071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008242224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty