Healthcare Provider Details

I. General information

NPI: 1871266072
Provider Name (Legal Business Name): JESSICA MARIE KOTSAKIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S 76TH ST
MILWAUKEE WI
53214-1599
US

IV. Provider business mailing address

1885 LONE OAK CIR W
BROOKFIELD WI
53045-5017
US

V. Phone/Fax

Practice location:
  • Phone: 414-453-1400
  • Fax: 414-453-2538
Mailing address:
  • Phone: 262-894-0742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: