Provider Demographics
NPI:1184947814
Name:JOTTER, MARMIE PAULINE (LICSW)
Entity type:Individual
Prefix:MS
First Name:MARMIE
Middle Name:PAULINE
Last Name:JOTTER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 E BELTLINE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2353
Mailing Address - Country:US
Mailing Address - Phone:218-263-5949
Mailing Address - Fax:218-263-8435
Practice Address - Street 1:3105 E BELTLINE
Practice Address - Street 2:SUITE 16
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2353
Practice Address - Country:US
Practice Address - Phone:218-263-5949
Practice Address - Fax:218-263-8435
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN182841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800002959/C09138OtherMEDICARE PROVIDER ENROLLMENT INDIVIDUAL/PTAN