Provider Demographics
NPI:1013794122
Name:SORTWELL, JESI NICOLE (TLLP)
Entity Type:Individual
Prefix:
First Name:JESI
Middle Name:NICOLE
Last Name:SORTWELL
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 KENNEDY CT
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1814
Mailing Address - Country:US
Mailing Address - Phone:616-320-2010
Mailing Address - Fax:
Practice Address - Street 1:238 HOOVER BLVD STE 10
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3755
Practice Address - Country:US
Practice Address - Phone:616-591-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009820103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist