Provider Demographics
NPI:1952704181
Name:WILLIAMS, JACINTA (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JACINTA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:JACINTA
Other - Middle Name:
Other - Last Name:FEIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1650 TRI PARK WAY
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1652
Mailing Address - Country:US
Mailing Address - Phone:920-830-6697
Mailing Address - Fax:
Practice Address - Street 1:1900 HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1097
Practice Address - Country:US
Practice Address - Phone:712-336-3797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00131224Z00000X
MN201724224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00131OtherCOTA LICENSE
MN201724OtherCOTA LICENSE