Provider Demographics
NPI:1760811285
Name:FORTIER-LICK, JESSICA (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FORTIER-LICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4572 S HAGADORN RD
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5385
Mailing Address - Country:US
Mailing Address - Phone:517-481-2133
Mailing Address - Fax:517-659-5934
Practice Address - Street 1:4572 S HAGADORN RD
Practice Address - Street 2:SUITE 1C
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5385
Practice Address - Country:US
Practice Address - Phone:517-481-2133
Practice Address - Fax:517-659-5934
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801084827104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker