Healthcare Provider Details

I. General information

NPI: 1043642978
Provider Name (Legal Business Name): JENNIFER M TIBBETTS M.ED, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18209 SR 410 E SUITE 304
BONNEY LAKE WA
98391-5146
US

IV. Provider business mailing address

18209 SR 410 E SUITE 304
BONNEY LAKE WA
98391-5146
US

V. Phone/Fax

Practice location:
  • Phone: 253-229-0322
  • Fax:
Mailing address:
  • Phone: 253-229-0322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00010675
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: