Provider Demographics
NPI:1497407688
Name:KOTERBA, JILLIAN RAE (RN)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:RAE
Last Name:KOTERBA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 HOLLYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1109
Mailing Address - Country:US
Mailing Address - Phone:989-205-7086
Mailing Address - Fax:
Practice Address - Street 1:713 HOLLYWOOD DR
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1109
Practice Address - Country:US
Practice Address - Phone:989-205-7086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-19
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704279051163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse