Provider Demographics
NPI:1194481705
Name:ORTIS, JESSICA MARIE (MA, LPCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:ORTIS
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-0060
Mailing Address - Country:US
Mailing Address - Phone:507-934-7799
Mailing Address - Fax:507-934-2594
Practice Address - Street 1:1715 SHEPPARD DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-2539
Practice Address - Country:US
Practice Address - Phone:507-934-7799
Practice Address - Fax:507-934-2594
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC03011101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health