Provider Demographics
NPI:1184178279
Name:BECKER, JENNA (COTA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BECKER
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:N9437 SARA LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-5206
Mailing Address - Country:US
Mailing Address - Phone:920-277-0531
Mailing Address - Fax:
Practice Address - Street 1:N9437 SARA LN
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-5206
Practice Address - Country:US
Practice Address - Phone:920-277-0531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-07
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5260-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant