Healthcare Provider Details

I. General information

NPI: 1144863606
Provider Name (Legal Business Name): JAYMI GOETZE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 8TH ST
HOQUIAM WA
98550-3522
US

IV. Provider business mailing address

PO BOX 1847
LONGVIEW WA
98632-8140
US

V. Phone/Fax

Practice location:
  • Phone: 360-532-4357
  • Fax:
Mailing address:
  • Phone: 360-423-0203
  • Fax: 360-577-0269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61011176
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: