Provider Demographics
NPI:1316694748
Name:WILCOX, JENNELL (COTA)
Entity type:Individual
Prefix:MS
First Name:JENNELL
Middle Name:
Last Name:WILCOX
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 1:1745 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-2619
Mailing Address - Country:US
Mailing Address - Phone:904-994-2795
Mailing Address - Fax:
Practice Address - Street 1:1745 E 24TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-2619
Practice Address - Country:US
Practice Address - Phone:904-994-2795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-05
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X, 171400000X, 224Z00000X, 372600000X
374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL236990OtherHOMEMAKERS & COMPANION SVCS
FLOTA17454OtherCOTA