Provider Demographics
NPI:1508404740
Name:ORTIZ, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:ORTIZ
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 1:1313 W FERGUSON AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-5604
Mailing Address - Country:US
Mailing Address - Phone:580-789-3100
Mailing Address - Fax:
Practice Address - Street 1:1313 W FERGUSON AVE
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-5604
Practice Address - Country:US
Practice Address - Phone:580-789-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1392101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor