MEDICARE: JAN OPEDAL M.S. CLINICAL PSYCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MHCA 60520453	WA

General Provider Information

NPI Number	:	1194114710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAN OPEDAL M.S. CLINICAL PSYCH

Provider Business Mailing Address
First Line	:	5262 OLYMPIC DR NW
Second Line	:	SUITE C
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-1795
Country	:	US
Telephone Number	:	425-577-8990
Fax Number	:

Provider Business Practice Location Address
First Line	:	5262 OLYMPIC DR NW
Second Line	:	SUITE C
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-1795
Country	:	US
Telephone Number	:	425-577-8990
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2015
Last Update Date	:	01/20/2015

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