Provider Demographics
NPI:1083656185
Name:KOTLARCZYK, JENNIFER LYNN (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:KOTLARCZYK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7216 US HIGHWAY 301 N
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-3462
Mailing Address - Country:US
Mailing Address - Phone:941-729-0003
Mailing Address - Fax:941-729-0004
Practice Address - Street 1:3030 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2502
Practice Address - Country:US
Practice Address - Phone:941-359-8233
Practice Address - Fax:941-359-8255
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2989794OtherAETNA GROUP PROV NUMBER
FL6606642OtherGHI INDIV PROV NUM
FLY061LOtherBCBS INDIV PROV NUM
FL890852400Medicaid
FL890852400Medicaid