Healthcare Provider Details

I. General information

NPI: 1578013710
Provider Name (Legal Business Name): JODY WITMAN MA MHP LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 BROADWAY ST STE 106
LONGVIEW WA
98632-3714
US

IV. Provider business mailing address

2428 W REYNOLDS AVE
CENTRALIA WA
98531-4554
US

V. Phone/Fax

Practice location:
  • Phone: 360-481-2866
  • Fax: 360-481-2866
Mailing address:
  • Phone: 360-330-9044
  • Fax: 360-736-3139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60953713
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: