Healthcare Provider Details

I. General information

NPI: 1487407300
Provider Name (Legal Business Name): JODY CLEVELAND RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 PACIFIC AVE N
LONG BEACH WA
98631-3802
US

IV. Provider business mailing address

229 25TH ST NW
LONG BEACH WA
98631-3825
US

V. Phone/Fax

Practice location:
  • Phone: 360-589-2425
  • Fax:
Mailing address:
  • Phone: 360-460-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN61490842
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN61490842
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: