Healthcare Provider Details

I. General information

NPI: 1679765226
Provider Name (Legal Business Name): KITSAP COUNTY JUVENILE DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 SW OLD CLIFTON RD
PORT ORCHARD WA
98367-9113
US

IV. Provider business mailing address

1338 SW OLD CLIFTON RD
PORT ORCHARD WA
98367-9113
US

V. Phone/Fax

Practice location:
  • Phone: 360-337-5401
  • Fax: 360-337-5404
Mailing address:
  • Phone: 360-337-5401
  • Fax: 360-337-5404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number18006700
License Number StateWA

VIII. Authorized Official

Name: MS. NANCY J WILSON
Title or Position: ADMINISTRATIVE SERVICES MANAGER
Credential:
Phone: 360-337-5401