Healthcare Provider Details

I. General information

NPI: 1639844376
Provider Name (Legal Business Name): MS. JEANNE MARIE POURROY-CARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10614 BEARDSLEE BLVD STE D
BOTHELL WA
98011-3279
US

IV. Provider business mailing address

10614 BEARDSLEE BLVD STE D
BOTHELL WA
98011-3279
US

V. Phone/Fax

Practice location:
  • Phone: 425-483-4664
  • Fax: 206-487-2721
Mailing address:
  • Phone: 425-483-4664
  • Fax: 206-487-2721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00003651
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier261QR0405X
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerPRIVATE INSURANCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: