Healthcare Provider Details

I. General information

NPI: 1699475848
Provider Name (Legal Business Name): KASSIE JO ROUDEBUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W 10TH AVE
KENNEWICK WA
99336-6300
US

IV. Provider business mailing address

402 S 4TH AVE
YAKIMA WA
98902-3546
US

V. Phone/Fax

Practice location:
  • Phone: 509-870-9150
  • Fax:
Mailing address:
  • Phone: 509-575-4084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: