Provider Demographics
NPI:1477033462
Name:ACOSTA, JAIME M (OTA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:M
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4946 WINTER CHERRY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-3715
Mailing Address - Country:US
Mailing Address - Phone:210-602-9555
Mailing Address - Fax:
Practice Address - Street 1:602 BABCOCK RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-3158
Practice Address - Country:US
Practice Address - Phone:210-731-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-18
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211114224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty