Healthcare Provider Details

I. General information

NPI: 1477508935
Provider Name (Legal Business Name): JENNIFER J. KOTTRA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 W STEVANNA WAY
FLAGSTAFF AZ
86001-1159
US

IV. Provider business mailing address

6830 E IRONWOOD DR
PARADISE VALLEY AZ
85253-2655
US

V. Phone/Fax

Practice location:
  • Phone: 928-699-6853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number28102
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036139297
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: