Healthcare Provider Details

I. General information

NPI: 1689232639
Provider Name (Legal Business Name): ELISSA CHARLENE JULES CP61224601
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 31ST AVE NE STE 101
TULALIP WA
98271-7423
US

IV. Provider business mailing address

6330 31ST AVE NE
TULALIP WA
98271-7423
US

V. Phone/Fax

Practice location:
  • Phone: 360-716-2200
  • Fax: 360-716-2211
Mailing address:
  • Phone: 360-716-2200
  • Fax: 360-716-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60902535
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61224601
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: