Provider Demographics
NPI:1700303294
Name:WILLIAMS, JENNA GRACE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:GRACE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:JENNA
Other - Middle Name:GRACE
Other - Last Name:WILGING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:401 OLD PLEASANT GROVE RD APT 712
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-7312
Mailing Address - Country:US
Mailing Address - Phone:419-564-2322
Mailing Address - Fax:
Practice Address - Street 1:3131 TOM AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-4801
Practice Address - Country:US
Practice Address - Phone:615-415-2010
Practice Address - Fax:615-634-3821
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH006205224Z00000X
OHOTA006205224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant