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Individual
MR. JACK LEE OTTERSTROM
Active
Individual
MR. JACK LEE OTTERSTROM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
L5316
OR
1041C0700X
Clinical Social Worker
L3516
OR
1041C0700X
Clinical Social Worker
Primary
—
OR
Other
Enumeration date
12/27/2006
Last updated
09/06/2022
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