Provider Demographics
NPI:1356998769
Name:MASON, JACLYN RENEE (COTAL)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:RENEE
Last Name:MASON
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 1:609 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-4606
Mailing Address - Country:US
Mailing Address - Phone:540-855-8525
Mailing Address - Fax:
Practice Address - Street 1:609 LAKE VISTA DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-4606
Practice Address - Country:US
Practice Address - Phone:540-855-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000570224Z00000X
GAOTA002507224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant