Healthcare Provider Details

I. General information

NPI: 1255967014
Provider Name (Legal Business Name): JODI LYNN KOUTSOVITIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KINGS WAY E STE B456
SEWELL NJ
08080-2237
US

IV. Provider business mailing address

1998 ROUTE 70 E
CHERRY HILL NJ
08003-1834
US

V. Phone/Fax

Practice location:
  • Phone: 856-256-0007
  • Fax:
Mailing address:
  • Phone: 856-424-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: