Healthcare Provider Details

I. General information

NPI: 1255161949
Provider Name (Legal Business Name): JENNIFER DUGAN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 ELOCHOMAN VALLEY RD
CATHLAMET WA
98612-9602
US

IV. Provider business mailing address

42 ELOCHOMAN VALLEY RD
CATHLAMET WA
98612-9602
US

V. Phone/Fax

Practice location:
  • Phone: 360-795-8630
  • Fax:
Mailing address:
  • Phone: 360-795-8630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG61277537
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: