Provider Demographics
NPI:1568016806
Name:OTTEN, JESSICA (NP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OTTEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WILLERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1618 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2332
Mailing Address - Country:US
Mailing Address - Phone:507-227-3724
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR38762363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner