Provider Demographics
NPI:1700244258
Name:ELLIOTT, JENNIFER (COTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:ELLIOTT
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 1:2209 KAITLYN DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-4243
Mailing Address - Country:US
Mailing Address - Phone:817-901-7197
Mailing Address - Fax:
Practice Address - Street 1:5417 ALTAMESA BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-2804
Practice Address - Country:US
Practice Address - Phone:817-292-8886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211994224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant