Provider Demographics
NPI:1477508935
Name:KOTTRA, JENNIFER J (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:KOTTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 2018
Mailing Address - Street 2:PO BOX 29675
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 W MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8409
Practice Address - Country:US
Practice Address - Phone:815-334-5566
Practice Address - Fax:815-759-4008
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ281022085R0202X
IL0361392972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ499378Medicaid
AZZ72173Medicare PIN
AZZ66419Medicare PIN
AZ300128754Medicare PIN
AZ499378Medicaid