Provider Demographics
NPI:1609230457
Name:JOE, JENNIFER (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOE
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 1:272 DOKE ST
Mailing Address - Street 2:
Mailing Address - City:WEST FORK
Mailing Address - State:AR
Mailing Address - Zip Code:72774-3114
Mailing Address - Country:US
Mailing Address - Phone:479-799-7671
Mailing Address - Fax:
Practice Address - Street 1:272 DOKE ST
Practice Address - Street 2:
Practice Address - City:WEST FORK
Practice Address - State:AR
Practice Address - Zip Code:72774-3114
Practice Address - Country:US
Practice Address - Phone:479-799-7671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant