Provider Demographics
NPI:1235501073
Name:KOTOUC, JIMMIE (BA, IADC)
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:
Last Name:KOTOUC
Suffix:
Gender:M
Credentials:BA, IADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 MAIN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6844
Mailing Address - Country:US
Mailing Address - Phone:563-582-3784
Mailing Address - Fax:563-582-4006
Practice Address - Street 1:799 MAIN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6844
Practice Address - Country:US
Practice Address - Phone:563-582-3784
Practice Address - Fax:563-582-4006
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14045101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)