Healthcare Provider Details

I. General information

NPI: 1760955272
Provider Name (Legal Business Name): BRYANNA MARIE JELLUM SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W MAIN ST
KELSO WA
98626-1118
US

IV. Provider business mailing address

404 W MAIN ST
KELSO WA
98626-1118
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-2806
  • Fax: 360-423-5128
Mailing address:
  • Phone: 360-423-2806
  • Fax: 360-423-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number60279397
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: