Healthcare Provider Details

I. General information

NPI: 1306296595
Provider Name (Legal Business Name): JENNA LEE HOTOVEC MS, PPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 S 4TH ST
LARAMIE WY
82070-3704
US

IV. Provider business mailing address

504 S 4TH ST
LARAMIE WY
82070-3704
US

V. Phone/Fax

Practice location:
  • Phone: 307-755-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number956
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: