Provider Demographics
NPI:1194065706
Name:ROBERTSON, JENNIFER LYNN (COTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ROBERTSON
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 1:103 RIVER BEND RD
Mailing Address - Street 2:APT. 2
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-4202
Mailing Address - Country:US
Mailing Address - Phone:262-515-5120
Mailing Address - Fax:
Practice Address - Street 1:103 RIVER BEND RD
Practice Address - Street 2:APT. 2
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-4202
Practice Address - Country:US
Practice Address - Phone:262-515-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2058-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant