Healthcare Provider Details

I. General information

NPI: 1982116687
Provider Name (Legal Business Name): JORDAN KOTWICKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5366 EASTERN AVE SE
KENTWOOD MI
49508-6018
US

IV. Provider business mailing address

4477 LAKE MICHIGAN DR APT B3
ALLENDALE MI
49401-9104
US

V. Phone/Fax

Practice location:
  • Phone: 616-608-3665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberK320439564172
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: