Provider Demographics
NPI:1134108293
Name:KOTUBY, JEANNE MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:MARY
Last Name:KOTUBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 PROSPECT PARK W
Mailing Address - Street 2:#44A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4267
Mailing Address - Country:US
Mailing Address - Phone:718-788-6886
Mailing Address - Fax:
Practice Address - Street 1:135 PROSPECT PARK W
Practice Address - Street 2:#44A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4267
Practice Address - Country:US
Practice Address - Phone:718-788-6886
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016044103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
257029OtherCOMPSYCH
P3587910OtherOXFORD HEALTH PLANS
NYVM9801Medicare ID - Type Unspecified