Healthcare Provider Details

I. General information

NPI: 1326658212
Provider Name (Legal Business Name): JENNIFER C ERVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER C GROVES

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 THOMPSON DR
SEDRO WOOLLEY WA
98284-5007
US

IV. Provider business mailing address

1960 THOMPSON DR
SEDRO WOOLLEY WA
98284-5007
US

V. Phone/Fax

Practice location:
  • Phone: 360-856-3186
  • Fax: 360-856-3138
Mailing address:
  • Phone: 360-856-3186
  • Fax: 360-856-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: