Provider Demographics
NPI:1851564264
Name:OTT, JEAN MARIE (COTA)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MARIE
Last Name:OTT
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 1:825 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1675
Mailing Address - Country:US
Mailing Address - Phone:920-623-2520
Mailing Address - Fax:920-623-9236
Practice Address - Street 1:825 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1675
Practice Address - Country:US
Practice Address - Phone:920-623-2520
Practice Address - Fax:920-623-9236
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1039-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40816800Medicaid