Healthcare Provider Details

I. General information

NPI: 1578028668
Provider Name (Legal Business Name): JESSICA MARIE FREEZE LICSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E 8TH ST
PORT ANGELES WA
98362-6129
US

IV. Provider business mailing address

118 E 8TH ST
PORT ANGELES WA
98362-6129
US

V. Phone/Fax

Practice location:
  • Phone: 360-477-0787
  • Fax:
Mailing address:
  • Phone: 360-457-0431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61217506
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: