Healthcare Provider Details

I. General information

NPI: 1265581748
Provider Name (Legal Business Name): JAMIE LYNN FORTIN L.L.B.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MEMORIAL RD
HOUGHTON MI
49931-2475
US

IV. Provider business mailing address

901 MEMORIAL RD
HOUGHTON MI
49931-2475
US

V. Phone/Fax

Practice location:
  • Phone: 906-884-4804
  • Fax: 906-482-0369
Mailing address:
  • Phone: 906-884-4804
  • Fax: 906-482-0369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802085690
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: