Healthcare Provider Details

I. General information

NPI: 1891984498
Provider Name (Legal Business Name): JEWELYA M IANNICIELLO SUDP, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 01/05/2025
Certification Date: 01/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 112TH ST E
TACOMA WA
98446-5307
US

IV. Provider business mailing address

5001 112TH ST E
TACOMA WA
98446-5307
US

V. Phone/Fax

Practice location:
  • Phone: 253-460-0062
  • Fax:
Mailing address:
  • Phone: 253-460-0062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00005115
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60174863
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: