Provider Demographics
NPI:1235490491
Name:ORTIZ, JENNIFER (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:PSYD
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 748519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8519
Mailing Address - Country:US
Mailing Address - Phone:904-376-3800
Mailing Address - Fax:904-376-3998
Practice Address - Street 1:87010 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3400
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:904-396-8969
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLPY10296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health