Healthcare Provider Details

I. General information

NPI: 1811485311
Provider Name (Legal Business Name): JACKILYN IMPER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 11TH AVE
LONGVIEW WA
98632-2555
US

IV. Provider business mailing address

945 11TH AVE
LONGVIEW WA
98632-2555
US

V. Phone/Fax

Practice location:
  • Phone: 503-720-4706
  • Fax:
Mailing address:
  • Phone: 503-308-1161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLW61481125
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61481125
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: