MEDICARE: JEFFRY ALAN COTTLE MA, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP0480	MN

General Provider Information

NPI Number	:	1003853292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFRY ALAN COTTLE MA, LP

Provider Business Mailing Address
First Line	:	4164 HEMLOCK LN
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55127-6111
Country	:	US
Telephone Number	:	651-308-7176
Fax Number	:

Provider Business Practice Location Address
First Line	:	4164 HEMLOCK LN
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55127-6111
Country	:	US
Telephone Number	:	651-308-7176
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	07/08/2007

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