Provider Demographics
NPI:1558969402
Name:COLTMAN, JESSICA LAUREN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:COLTMAN
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 1:1109 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ALGONAC
Mailing Address - State:MI
Mailing Address - Zip Code:48001-1420
Mailing Address - Country:US
Mailing Address - Phone:810-643-6716
Mailing Address - Fax:
Practice Address - Street 1:26210 HARPER AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2203
Practice Address - Country:US
Practice Address - Phone:888-485-8636
Practice Address - Fax:586-218-3367
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2023-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician