Healthcare Provider Details

I. General information

NPI: 1083630974
Provider Name (Legal Business Name): JEANINE E. KOTSCHWAR PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANINE E ENTINGH

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 S COLUMBIA RD SUITE 202
GRAND FORKS ND
58201-5895
US

IV. Provider business mailing address

2100 S COLUMBIA RD SUITE 202
GRAND FORKS ND
58201-5895
US

V. Phone/Fax

Practice location:
  • Phone: 701-772-1588
  • Fax: 701-746-6077
Mailing address:
  • Phone: 701-772-1588
  • Fax: 701-746-6077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number177
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: