Provider Demographics
NPI:1922163096
Name:OTTERSTROM, JACK LEE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:LEE
Last Name:OTTERSTROM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:JAY
Other - Middle Name:LEE
Other - Last Name:OTTERSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSCW
Mailing Address - Street 1:619 BROAD ST S # 19
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-2372
Mailing Address - Country:US
Mailing Address - Phone:412-318-0235
Mailing Address - Fax:
Practice Address - Street 1:656 JASMINE CIR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OR
Practice Address - Zip Code:97351-9578
Practice Address - Country:US
Practice Address - Phone:541-231-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL5316101YP2500X
ORL35161041C0700X
OR1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR145387Medicaid