Healthcare Provider Details

I. General information

NPI: 1972804441
Provider Name (Legal Business Name): MS. JESSIE JADE PAQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSIE JADE JIMMICUM

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24373 HIGHWAY 112 STE 2
CLALLAM BAY WA
98326-9606
US

IV. Provider business mailing address

1026 EAST FIRST STREET SUITE 2
PORT ANGELES WA
98362
US

V. Phone/Fax

Practice location:
  • Phone: 360-640-8127
  • Fax:
Mailing address:
  • Phone: 360-452-4432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: