Provider Demographics
NPI:1972294502
Name:ORTEGA, JESSICA MARIE (PMHNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:ORTEGA
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:KRAWZIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP
Mailing Address - Street 1:1448 SOUTH 15TH ST.
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40210
Mailing Address - Country:US
Mailing Address - Phone:502-290-5030
Mailing Address - Fax:502-290-4073
Practice Address - Street 1:1448 SOUTH 15TH ST.
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210
Practice Address - Country:US
Practice Address - Phone:502-290-5030
Practice Address - Fax:502-290-4073
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4002490363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100898730Medicaid