Provider Demographics
NPI:1952745838
Name:DAVIS, JIBRAIL (COTA)
Entity Type:Individual
Prefix:
First Name:JIBRAIL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13015 223RD ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1243
Mailing Address - Country:US
Mailing Address - Phone:718-785-3911
Mailing Address - Fax:
Practice Address - Street 1:3505 AVENUE S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4827
Practice Address - Country:US
Practice Address - Phone:718-787-1772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0082071224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant