Provider Demographics
NPI:1831735760
Name:KOTECKI, JACOB THOMAS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:KOTECKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2399 N BLOOMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-1307
Mailing Address - Country:US
Mailing Address - Phone:815-672-6874
Mailing Address - Fax:
Practice Address - Street 1:2399 N BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-1307
Practice Address - Country:US
Practice Address - Phone:815-672-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist