Provider Demographics
NPI:1760169676
Name:SMITH, JENNIFER (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMITH
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 1:11137 BITTERSWEET ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3555
Mailing Address - Country:US
Mailing Address - Phone:763-229-2426
Mailing Address - Fax:
Practice Address - Street 1:14585 59TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3872
Practice Address - Country:US
Practice Address - Phone:763-519-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202232224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant