Provider Demographics
NPI:1396163002
Name:OTIS, JESSICA (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12971 S SHAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7805
Mailing Address - Country:US
Mailing Address - Phone:801-910-5587
Mailing Address - Fax:801-206-3618
Practice Address - Street 1:12971 S SHAWNEE DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7805
Practice Address - Country:US
Practice Address - Phone:801-910-5587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-9251041C0700X
AK1130511041C0700X
IDLCSW-360301041C0700X
UT8696808-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical