Healthcare Provider Details

I. General information

NPI: 1588579817
Provider Name (Legal Business Name): MERLE BENIDICT JEFFERSON JR. SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2588 KWINA RD
BELLINGHAM WA
98226-9278
US

IV. Provider business mailing address

2588 KWINA RD
BELLINGHAM WA
98226-9278
US

V. Phone/Fax

Practice location:
  • Phone: 360-380-8633
  • Fax: 360-380-8570
Mailing address:
  • Phone: 360-380-8633
  • Fax: 360-380-8570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number61638844
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: