Provider Demographics
NPI:1699482448
Name:JACQUELINE KOZAK
Entity type:Organization
Organization Name:JACQUELINE KOZAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-361-7304
Mailing Address - Street 1:4402 WILLIAMS DR STE 115
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1388
Mailing Address - Country:US
Mailing Address - Phone:512-256-7627
Mailing Address - Fax:
Practice Address - Street 1:4402 WILLIAMS DR
Practice Address - Street 2:115
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1388
Practice Address - Country:US
Practice Address - Phone:512-256-7627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-01
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
15748686OtherCAQH