MEDICARE: JESSICA GOVAN

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		WA

General Provider Information

NPI Number	:	1801496021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GOVAN

Provider Business Mailing Address
First Line	:	518 S 7TH ST APT 101
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98402-2209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7424 BRIDGEPORT WAY W STE 305
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-8135
Country	:	US
Telephone Number	:	253-246-6820
Fax Number	:

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

Provider Enumeration Date	:	10/27/2020
Last Update Date	:	10/27/2020

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