Provider Demographics
NPI:1366806887
Name:WIERTELLA, JYOTISH (LMSW)
Entity type:Individual
Prefix:
First Name:JYOTISH
Middle Name:
Last Name:WIERTELLA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5243
Mailing Address - Country:US
Mailing Address - Phone:906-299-3208
Mailing Address - Fax:906-257-6736
Practice Address - Street 1:512 SCHOOL SCHOOLCRAFT ROAD
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-299-3208
Practice Address - Fax:906-257-6736
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802088919104100000X
MI68011172161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker