Provider Demographics
NPI:1144041757
Name:SMITH, JENNIFER (COTA/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMITH
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 1:21 JACKE LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12743-5012
Mailing Address - Country:US
Mailing Address - Phone:845-428-4370
Mailing Address - Fax:
Practice Address - Street 1:60 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1122
Practice Address - Country:US
Practice Address - Phone:845-794-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011628224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant