Healthcare Provider Details

I. General information

NPI: 1497361844
Provider Name (Legal Business Name): JENNINE KOTNIK RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 NE 45TH ST
SEATTLE WA
98105-5002
US

IV. Provider business mailing address

3020 NE 45TH ST
SEATTLE WA
98105-5002
US

V. Phone/Fax

Practice location:
  • Phone: 206-524-9931
  • Fax:
Mailing address:
  • Phone: 206-524-9931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number61077920
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: