MEDICARE: CLALLAM COUNTY JUVENILE AND FAMILY SERVICES

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	261QR0400X	Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	91136	OTHER	WA	PSE HEALTHTRUST
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326139528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLALLAM COUNTY JUVENILE AND FAMILY SERVICES

Provider Business Mailing Address
First Line	:	1912 W 18TH ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98363-5121
Country	:	US
Telephone Number	:	360-565-2621
Fax Number	:	360-457-4875

Provider Business Practice Location Address
First Line	:	1912 W 18TH ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98363-5121
Country	:	US
Telephone Number	:	360-565-2621
Fax Number	:	360-457-4875

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	PETE PETERSON
Credential	:
Telephone Number	:	360-565-2628

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	08/22/2020

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