Individual
MR. JACK LEE OTTERSTROM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
656 JASMINE CIR, INDEPENDENCE, OR 97351-9578
(541) 231-8023
Mailing address
619 BROAD ST S # 19, MONMOUTH, OR 97361-2372
(412) 318-0235
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
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
R145387
—
OR
Enumeration date
12/27/2006
Last updated
09/06/2022
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