Provider Demographics
NPI:1265265417
Name:WILLIS, JAMIE DAWN (COTA/L)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:DAWN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7801
Mailing Address - Country:US
Mailing Address - Phone:405-694-7570
Mailing Address - Fax:
Practice Address - Street 1:3221 24TH AVE NW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6738
Practice Address - Country:US
Practice Address - Phone:405-857-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2652224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant