Provider Demographics
NPI:1528183084
Name:COMMONS, JACQUELYN (COTA)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:COMMONS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JACXQUELYN
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3210 BIG VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4397
Mailing Address - Country:US
Mailing Address - Phone:863-648-9781
Mailing Address - Fax:
Practice Address - Street 1:2120 MARSHALL EDWARDS DR
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-6731
Practice Address - Country:US
Practice Address - Phone:863-534-1862
Practice Address - Fax:863-533-5458
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCOTA9762224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant