Healthcare Provider Details

I. General information

NPI: 1407554660
Provider Name (Legal Business Name): MR. JUSTIN ALLEN POWERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 W FRANKLIN ST
SHELTON WA
98584-3504
US

IV. Provider business mailing address

1800 SIDNEY AVE APT 4-116
PORT ORCHARD WA
98366-2424
US

V. Phone/Fax

Practice location:
  • Phone: 360-763-5610
  • Fax:
Mailing address:
  • Phone: 787-342-3845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCGCG61413793
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61653011
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: