Healthcare Provider Details

I. General information

NPI: 1982240313
Provider Name (Legal Business Name): KAITLIN JEAN CLEMENTS JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAITLIN JEAN CLEMENTS

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COLUMBIA WELLNESS 720 14TH AVE
LONGVIEW WA
98632
US

IV. Provider business mailing address

COLUMBIA WELLNESS 720 14TH AVE
LONGVIEW WA
98632
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-2211
  • Fax: 360-577-0187
Mailing address:
  • Phone: 360-353-9396
  • Fax: 360-577-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG61023510
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: