Provider Demographics
NPI:1881389013
Name:KOLTZ, JESSIE LEIGH (PHD,NCC,NCSC,ACMHC)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:LEIGH
Last Name:KOLTZ
Suffix:
Gender:F
Credentials:PHD,NCC,NCSC,ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-2810
Mailing Address - Country:US
Mailing Address - Phone:435-797-1250
Mailing Address - Fax:
Practice Address - Street 1:2810 OLD MAIN HL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-2810
Practice Address - Country:US
Practice Address - Phone:435-797-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12557230-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health