Provider Demographics
NPI:1548530280
Name:MERTZ, JESSICA MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:MERTZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:CLAUSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, MSW
Mailing Address - Street 1:7151 15TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6613
Mailing Address - Country:US
Mailing Address - Phone:701-364-2950
Mailing Address - Fax:701-364-2953
Practice Address - Street 1:7151 15TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6613
Practice Address - Country:US
Practice Address - Phone:701-364-2950
Practice Address - Fax:701-364-2953
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND44901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND4490OtherLICENSE