Provider Demographics
NPI:1841526589
Name:HERRING, JETTA COLLEEN (COTA)
Entity type:Individual
Prefix:MS
First Name:JETTA
Middle Name:COLLEEN
Last Name:HERRING
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 1:11508 DARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-6472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11508 DARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-6472
Practice Address - Country:US
Practice Address - Phone:661-679-4456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-01
Last Update Date:2009-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA1704224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOTA 1704OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY
MD235417OtherNATIONAL BOARD OF CERTIFICATION IN OCCUPATIONAL THERAPY, INC.