Healthcare Provider Details

I. General information

NPI: 1174883888
Provider Name (Legal Business Name): JESSICA EMILY KOTA LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 LAWNDALE ST
DETROIT MI
48210-2010
US

IV. Provider business mailing address

5315 RAVENSWOOD RD
KIMBALL MI
48074-3215
US

V. Phone/Fax

Practice location:
  • Phone: 313-846-6030
  • Fax:
Mailing address:
  • Phone: 517-614-0394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094178
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: