MEDICARE: JESSICA JOYCE COLTER MSW, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	28194	MN

General Provider Information

NPI Number	:	1801554944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA JOYCE COLTER MSW, LICSW

Provider Business Mailing Address
First Line	:	217 NW 1ST AVE
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-2702
Country	:	US
Telephone Number	:	218-750-0922
Fax Number	:	651-925-0610

Provider Business Practice Location Address
First Line	:	217 NW 1ST AVE
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-2702
Country	:	US
Telephone Number	:	218-750-0922
Fax Number	:	651-925-0610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2021
Last Update Date	:	12/06/2021

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