Healthcare Provider Details

I. General information

NPI: 1851143549
Provider Name (Legal Business Name): JAMEE DIANE PUCCIO MASTERS STUDENT INTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAMEE DIANE ESLICKER

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 W HOOD AVE STE D2
SISTERS OR
97759-1529
US

IV. Provider business mailing address

615 N MEADOW LN
SISTERS OR
97759-3148
US

V. Phone/Fax

Practice location:
  • Phone: 541-640-9310
  • Fax: 360-326-1978
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: