Provider Demographics
NPI:1992103949
Name:JEFFESON, NICOLE ANN (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:JEFFESON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:PAULDING
Mailing Address - State:OH
Mailing Address - Zip Code:45879-1211
Mailing Address - Country:US
Mailing Address - Phone:419-399-4711
Mailing Address - Fax:
Practice Address - Street 1:202 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879-1211
Practice Address - Country:US
Practice Address - Phone:419-399-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04275224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant