Healthcare Provider Details

I. General information

NPI: 1760960447
Provider Name (Legal Business Name): JESSICA LYNN GOUTREMOUT MSW INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 09/18/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 J.B. WISE PLAZA
WATERTOWN NY
13601
US

IV. Provider business mailing address

PO BOX 6550
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-782-7445
  • Fax: 315-779-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberP103556
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109063
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: