Provider Demographics
NPI:1568154839
Name:KOTCHER, JENNIFER RAE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:KOTCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RAE
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1145 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2336
Mailing Address - Country:US
Mailing Address - Phone:313-324-8900
Mailing Address - Fax:
Practice Address - Street 1:1145 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2336
Practice Address - Country:US
Practice Address - Phone:313-324-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist