Provider Demographics
NPI:1932389103
Name:COTTRELL, JEAN (RN)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:COTTRELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-1315
Mailing Address - Country:US
Mailing Address - Phone:262-363-4429
Mailing Address - Fax:262-363-0558
Practice Address - Street 1:118 SHORE DR
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1315
Practice Address - Country:US
Practice Address - Phone:262-363-4429
Practice Address - Fax:262-363-0558
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI75622-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35045100Medicaid