Healthcare Provider Details

I. General information

NPI: 1104676105
Provider Name (Legal Business Name): TIFFANY NICOELL JEPPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9932 36TH ST SE
LAKE STEVENS WA
98258-5703
US

IV. Provider business mailing address

828 HEALTHY WAY
VIRGINIA BEACH VA
23462-7958
US

V. Phone/Fax

Practice location:
  • Phone: 208-724-7419
  • Fax:
Mailing address:
  • Phone: 757-965-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH70006276
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701013410
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: