Basic Information
| Provider Information | |||||||||
| NPI: | 1841751112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAROSIK | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BARTELS | ||||||||
| OtherFirstName: | SHANNON | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5285 | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688025285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086751853 | ||||||||
| FaxNumber: | 3082104121 | ||||||||
| Practice Location | |||||||||
| Address1: | 1924 W A ST | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689015650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024617578 | ||||||||
| FaxNumber: | 4024617509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 973 | NE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.