Provider Demographics
NPI:1528932456
Name:WATERKOTTE, JANA R
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:R
Last Name:WATERKOTTE
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 1:101 PRAIRIE MILLS RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62339-1016
Mailing Address - Country:US
Mailing Address - Phone:217-696-4421
Mailing Address - Fax:217-696-4393
Practice Address - Street 1:101 PRAIRIE MILLS RD
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:IL
Practice Address - Zip Code:62339-1016
Practice Address - Country:US
Practice Address - Phone:217-696-4421
Practice Address - Fax:217-696-4393
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0009175314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility