Provider Demographics
NPI:1497361844
Name:KOTNIK, JENNINE (RPH)
Entity Type:Individual
Prefix:
First Name:JENNINE
Middle Name:
Last Name:KOTNIK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 NE 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5002
Mailing Address - Country:US
Mailing Address - Phone:206-524-9931
Mailing Address - Fax:
Practice Address - Street 1:3020 NE 45TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5002
Practice Address - Country:US
Practice Address - Phone:206-524-9931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61077920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61077920OtherRPH LICENSE