Provider Demographics
NPI:1346093879
Name:DILLON, JAKE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:DILLON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11660 ALPHARETTA HWY
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4943
Mailing Address - Country:US
Mailing Address - Phone:678-679-2932
Mailing Address - Fax:470-533-1522
Practice Address - Street 1:11660 ALPHARETTA HWY
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4943
Practice Address - Country:US
Practice Address - Phone:678-679-2932
Practice Address - Fax:470-533-1522
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA003041224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty