Provider Demographics
NPI:1871266072
Name:KOTSAKIS, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:KOTSAKIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1885 LONE OAK CIR W
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5017
Mailing Address - Country:US
Mailing Address - Phone:262-894-0742
Mailing Address - Fax:
Practice Address - Street 1:620 S 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-1599
Practice Address - Country:US
Practice Address - Phone:414-453-1400
Practice Address - Fax:414-453-2538
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871266072Medicaid