Provider Demographics
NPI:1104100130
Name:FORTNER, JESSICA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:FORTNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 COUNTY ROAD 371
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-3998
Mailing Address - Country:US
Mailing Address - Phone:662-607-0111
Mailing Address - Fax:
Practice Address - Street 1:194 COUNTY ROAD 371
Practice Address - Street 2:
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965-3998
Practice Address - Country:US
Practice Address - Phone:662-607-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist