Healthcare Provider Details

I. General information

NPI: 1598651929
Provider Name (Legal Business Name): JENESSA LYNN ROTTER LMSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 E MAIN ST STE 401
BOZEMAN MT
59715-5045
US

IV. Provider business mailing address

7311W ISLAND LAKE RD
HURLEY WI
54534-9220
US

V. Phone/Fax

Practice location:
  • Phone: 986-206-0414
  • Fax:
Mailing address:
  • Phone: 608-790-5103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number136393-121
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC26562
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851117583
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: