Provider Demographics
NPI:1922338896
Name:COTTA, JEFFERY ALAN PATEE (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ALAN PATEE
Last Name:COTTA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1164
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98586-1164
Mailing Address - Country:US
Mailing Address - Phone:564-888-3000
Mailing Address - Fax:
Practice Address - Street 1:205 8TH ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-2507
Practice Address - Country:US
Practice Address - Phone:360-764-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 253591041C0700X
WALW601069461041C0700X
WALW30106946104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1922338896Medicaid
CA192233896Medicaid
CA1922338896Medicaid
CA1922338896Medicare PIN
CA192233896Medicaid
CA1922338896Medicare NSC