Provider Demographics
NPI:1548641228
Name:FROST, JERRY (COTA)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:FROST
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-3405
Mailing Address - Country:US
Mailing Address - Phone:812-662-7778
Mailing Address - Fax:
Practice Address - Street 1:950 N LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-3405
Practice Address - Country:US
Practice Address - Phone:812-662-7778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000894A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant