Provider Demographics
NPI:1790124410
Name:KOTKIN, JESSICA BROOKE (MS SLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:BROOKE
Last Name:KOTKIN
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E 86TH ST APT 1VE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-4761
Mailing Address - Country:US
Mailing Address - Phone:516-456-3632
Mailing Address - Fax:
Practice Address - Street 1:315 E 86TH ST APT 1VE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-4761
Practice Address - Country:US
Practice Address - Phone:516-456-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-15
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist