Provider Demographics
NPI:1710523956
Name:LITTLE, JENIFER (COTAL)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:LITTLE
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11675 EDSEL DR
Mailing Address - Street 2:
Mailing Address - City:STANFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:28163-7500
Mailing Address - Country:US
Mailing Address - Phone:704-254-2815
Mailing Address - Fax:
Practice Address - Street 1:3700 TAYLOR GLEN LN NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-3400
Practice Address - Country:US
Practice Address - Phone:704-788-6510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3645224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification