Provider Demographics
NPI:1700092913
Name:KOHOUTEK, JESSICA SUZANNE (CPNP, RN)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:SUZANNE
Last Name:KOHOUTEK
Suffix:
Gender:F
Credentials:CPNP, RN
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Other - First Name:
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Mailing Address - Street 1:205 E 73RD ST APT 12A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3669
Mailing Address - Country:US
Mailing Address - Phone:212-439-9722
Mailing Address - Fax:
Practice Address - Street 1:1143 47TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5418
Practice Address - Country:US
Practice Address - Phone:718-551-3515
Practice Address - Fax:718-551-3580
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381673363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics