Healthcare Provider Details

I. General information

NPI: 1225960107
Provider Name (Legal Business Name): LAKESHORE MIND AND FAMILY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 COMMERCE AVE STE 301
LONGVIEW WA
98632-3726
US

IV. Provider business mailing address

1338 COMMERCE AVE STE 301
LONGVIEW WA
98632-3726
US

V. Phone/Fax

Practice location:
  • Phone: 360-984-9018
  • Fax:
Mailing address:
  • Phone: 360-984-9018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ANIEZKA M JENISSEN
Title or Position: MANAGING MEMBER
Credential: LMHC
Phone: 360-984-9018