Healthcare Provider Details

I. General information

NPI: 1922827237
Provider Name (Legal Business Name): JACKSON CADE DANTE GUZZO MA, LMHCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W SPRAGUE AVE
SPOKANE WA
99201-3627
US

IV. Provider business mailing address

210 W SPRAGUE AVE
SPOKANE WA
99201-3627
US

V. Phone/Fax

Practice location:
  • Phone: 509-343-5077
  • Fax: 509-747-8004
Mailing address:
  • Phone: 509-343-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.61569303
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: