Provider Demographics
NPI:1942579966
Name:OTTMAR, JASMINE (LICSW)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:OTTMAR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:
Other - Last Name:JILEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6046 14TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7340
Mailing Address - Country:US
Mailing Address - Phone:701-209-0319
Mailing Address - Fax:
Practice Address - Street 1:6046 14TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7340
Practice Address - Country:US
Practice Address - Phone:701-404-0997
Practice Address - Fax:701-566-8876
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4446101Y00000X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1471882Medicaid