Healthcare Provider Details

I. General information

NPI: 1083701015
Provider Name (Legal Business Name): JEFFERSON COMMUNITY COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

884 W PARK AVE
PORT TOWNSEND WA
98368-2273
US

IV. Provider business mailing address

PO BOX 565
PORT TOWNSEND WA
98368-0565
US

V. Phone/Fax

Practice location:
  • Phone: 360-385-0321
  • Fax: 360-379-2547
Mailing address:
  • Phone: 360-385-0321
  • Fax: 360-379-2547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TONYA M FERGUSON
Title or Position: DIRECTOR OF OPERATIONS AND COMPLIAN
Credential:
Phone: 360-385-0321