Healthcare Provider Details

I. General information

NPI: 1629891932
Provider Name (Legal Business Name): JENNIFER KOTALAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 GOOD RD
SEVILLE OH
44273-9722
US

IV. Provider business mailing address

3605 GOOD RD
SEVILLE OH
44273-9722
US

V. Phone/Fax

Practice location:
  • Phone: 330-421-8031
  • Fax:
Mailing address:
  • Phone: 330-421-8031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: