Provider Demographics
NPI:1578058012
Name:DITTY, JESSICA MARIE (MM, MT-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:DITTY
Suffix:
Gender:F
Credentials:MM, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 NELSON RD STE 221
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6399
Mailing Address - Country:US
Mailing Address - Phone:303-349-8918
Mailing Address - Fax:
Practice Address - Street 1:1430 NELSON RD STE 221
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6399
Practice Address - Country:US
Practice Address - Phone:303-349-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11114225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47-4625091Medicaid