Provider Demographics
NPI:1871643965
Name:EVANS, JUAN Z (COTA-L)
Entity Type:Individual
Prefix:MS
First Name:JUAN
Middle Name:Z
Last Name:EVANS
Suffix:
Gender:F
Credentials:COTA-L
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3072 FLEETWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-2545
Mailing Address - Country:US
Mailing Address - Phone:601-346-5555
Mailing Address - Fax:601-351-8229
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:601-605-8869
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA1660224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant