Healthcare Provider Details

I. General information

NPI: 1770175986
Provider Name (Legal Business Name): JAMES EARL WHITE JR. SUDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 AUBURN WAY N
AUBURN WA
98002-4335
US

IV. Provider business mailing address

PO BOX 544
GRAHAM WA
98338-0544
US

V. Phone/Fax

Practice location:
  • Phone: 253-939-2211
  • Fax:
Mailing address:
  • Phone: 540-642-2275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61453885
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: