Provider Demographics
NPI:1043868334
Name:ORTIZ, JESSICA LEIGH (TLLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18995 WHITBY ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3035
Mailing Address - Country:US
Mailing Address - Phone:616-566-8250
Mailing Address - Fax:
Practice Address - Street 1:26105 ORCHARD LAKE RD STE 207
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4578
Practice Address - Country:US
Practice Address - Phone:248-662-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362002993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical