MEDICARE: MS. JESSICA BROOKE KOTKIN M.S. SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist		NY

General Provider Information

NPI Number	:	1790124410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA BROOKE KOTKIN M.S. SLP

Provider Business Mailing Address
First Line	:	315 E 86TH ST APT 1VE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10028-4761
Country	:	US
Telephone Number	:	516-456-3632
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 E 86TH ST APT 1VE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10028-4761
Country	:	US
Telephone Number	:	516-456-3632
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2013
Last Update Date	:	06/25/2015

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