Provider Demographics
NPI:1770128738
Name:STEPHENS, KRISTEN MARIE (COTA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:STEPHENS
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 1:2219 NATHAN DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4467
Mailing Address - Country:US
Mailing Address - Phone:904-226-6640
Mailing Address - Fax:
Practice Address - Street 1:7723 JASPER AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-7719
Practice Address - Country:US
Practice Address - Phone:904-725-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14857224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant