Provider Demographics
NPI:1376747121
Name:DENKINS, JERELYN SUSAN (COTA L)
Entity Type:Individual
Prefix:MS
First Name:JERELYN
Middle Name:SUSAN
Last Name:DENKINS
Suffix:
Gender:F
Credentials:COTA L
Other - Prefix:MS
Other - First Name:JERELYN
Other - Middle Name:SUSAN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA L
Mailing Address - Street 1:103 S ERFIE DR
Mailing Address - Street 2:
Mailing Address - City:PINEBLUFF
Mailing Address - State:NC
Mailing Address - Zip Code:28373-8296
Mailing Address - Country:US
Mailing Address - Phone:910-528-4465
Mailing Address - Fax:
Practice Address - Street 1:103 S ERFIE DR
Practice Address - Street 2:
Practice Address - City:PINEBLUFF
Practice Address - State:NC
Practice Address - Zip Code:28373-8296
Practice Address - Country:US
Practice Address - Phone:910-528-4465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1124224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124OtherOTA L