Provider Demographics
NPI:1588994701
Name:CLOUTIER, JESSICA MARIE (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:CLOUTIER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:CHAMBERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLPC
Mailing Address - Street 1:1939 DIVISION AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-2459
Mailing Address - Country:US
Mailing Address - Phone:616-247-3815
Mailing Address - Fax:616-245-0450
Practice Address - Street 1:640 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8209
Practice Address - Country:US
Practice Address - Phone:616-785-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011184101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4483587Medicaid