1841479342 NPI number — MISS SHAWN NICHOLE JACKSON COTA

Table of content: MISS SHAWN NICHOLE JACKSON COTA (NPI 1841479342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841479342 NPI number — MISS SHAWN NICHOLE JACKSON COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
SHAWN
Provider Middle Name:
NICHOLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841479342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9252 ASHLAND WOODS LN
Provider Second Line Business Mailing Address:
APT A2
Provider Business Mailing Address City Name:
LORTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22079-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-339-0534
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 ROUTE 70 E
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08034-2210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-670-3893
Provider Business Practice Location Address Fax Number:
856-482-8498
Provider Enumeration Date:
10/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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