Provider Demographics
NPI:1730347006
Name:JACOB, AMY ANNA (COTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ANNA
Last Name:JACOB
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 1:27672 ONION HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:LONE ROCK
Mailing Address - State:WI
Mailing Address - Zip Code:53556-9002
Mailing Address - Country:US
Mailing Address - Phone:608-475-9151
Mailing Address - Fax:
Practice Address - Street 1:27672 ONION HOLLOW LANE
Practice Address - Street 2:
Practice Address - City:LONE ROCK
Practice Address - State:WI
Practice Address - Zip Code:53556-9002
Practice Address - Country:US
Practice Address - Phone:608-475-9151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI899027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant