Provider Demographics
NPI:1801554944
Name:COLTER, JESSICA JOYCE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOYCE
Last Name:COLTER
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 NW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2702
Mailing Address - Country:US
Mailing Address - Phone:218-750-0922
Mailing Address - Fax:651-925-0610
Practice Address - Street 1:217 NW 1ST AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2702
Practice Address - Country:US
Practice Address - Phone:218-750-0922
Practice Address - Fax:651-925-0610
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN281941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical