Healthcare Provider Details

I. General information

NPI: 1114301280
Provider Name (Legal Business Name): JACQUELYN WOLVERTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BROADWAY STE 301
TACOMA WA
98402-4454
US

IV. Provider business mailing address

950 BROADWAY STE 301
TACOMA WA
98402-4454
US

V. Phone/Fax

Practice location:
  • Phone: 253-292-4354
  • Fax: 855-373-4004
Mailing address:
  • Phone: 253-292-4354
  • Fax: 855-373-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: