Provider Demographics
NPI:1083630974
Name:KOTSCHWAR, JEANINE E (PHD)
Entity type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:E
Last Name:KOTSCHWAR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:E
Other - Last Name:ENTINGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 S COLUMBIA RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5895
Mailing Address - Country:US
Mailing Address - Phone:701-772-1588
Mailing Address - Fax:701-746-6077
Practice Address - Street 1:2100 S COLUMBIA RD
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5895
Practice Address - Country:US
Practice Address - Phone:701-772-1588
Practice Address - Fax:701-746-6077
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND177103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN197M7K0OtherMN BLUE CROSS
MN366850900Medicaid
NDKOT22727OtherND BLUE CROSS
ND16917Medicaid
MN366850900Medicaid