Provider Demographics
NPI:1700653516
Name:FORTIER, JENNIFER L (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:FORTIER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:MASI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7811 HOLLOW OAKS LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-8386
Mailing Address - Country:US
Mailing Address - Phone:518-577-5054
Mailing Address - Fax:
Practice Address - Street 1:11945 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4454
Practice Address - Country:US
Practice Address - Phone:980-245-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9653224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant