Healthcare Provider Details

I. General information

NPI: 1356869101
Provider Name (Legal Business Name): MR. JAMIE LOUIS OTTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 ORCHARD LAKE RD
PONTIAC MI
48341-2244
US

IV. Provider business mailing address

391 S SHORE DR STE 214
BATTLE CREEK MI
49014-5446
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-7766
  • Fax: 248-858-7258
Mailing address:
  • Phone: 269-964-0153
  • Fax: 855-877-5812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801109071
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: