Provider Demographics
NPI:1982116687
Name:KOTWICKI, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:KOTWICKI
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 1:4477 LAKE MICHIGAN DR APT B3
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-9104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5366 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-6018
Practice Address - Country:US
Practice Address - Phone:616-608-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIK320439564172106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY912541209OtherINDEPENDENT HEALTH