MEDICARE: JESSICA OTTO LSW

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	171M00000X	Case Manager/Care Coordinator
2	104100000X	Social Worker	7721S	NV

General Provider Information

NPI Number	:	1164921029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA OTTO LSW

Provider Business Mailing Address
First Line	:	4520 S PECOS RD STE 3
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5937
Country	:	US
Telephone Number	:	702-685-9220
Fax Number	:

Provider Business Practice Location Address
First Line	:	4520 S PECOS RD STE 3
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5937
Country	:	US
Telephone Number	:	702-685-9220
Fax Number	:	702-685-6221

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

Provider Enumeration Date	:	02/06/2018
Last Update Date	:	02/06/2018

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