Healthcare Provider Details

I. General information

NPI: 1902283070
Provider Name (Legal Business Name): JAMES L HOAG JR. A.A.S., SUDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 04/09/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S MERIDIAN
PUYALLUP WA
98371-6995
US

IV. Provider business mailing address

5401 S 12TH ST APT 1304
TACOMA WA
98465-2614
US

V. Phone/Fax

Practice location:
  • Phone: 253-290-0431
  • Fax: 253-517-3531
Mailing address:
  • Phone: 253-988-2191
  • Fax: 253-272-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60183363
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60534205
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: