Healthcare Provider Details

I. General information

NPI: 1811473036
Provider Name (Legal Business Name): JANICE LYNNE JEPSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3629 S D ST
TACOMA WA
98418-6813
US

IV. Provider business mailing address

3629 S D ST
TACOMA WA
98418-6813
US

V. Phone/Fax

Practice location:
  • Phone: 253-798-3576
  • Fax:
Mailing address:
  • Phone: 253-798-3576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number60068237
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: