Provider Demographics
NPI:1376240960
Name:FORTNER, JAMI S
Entity Type:Individual
Prefix:
First Name:JAMI
Middle Name:S
Last Name:FORTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 SHAMROCK CT
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5337
Mailing Address - Country:US
Mailing Address - Phone:228-497-0690
Mailing Address - Fax:
Practice Address - Street 1:57 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6583
Practice Address - Country:US
Practice Address - Phone:601-947-4274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid