Healthcare Provider Details

I. General information

NPI: 1831536903
Provider Name (Legal Business Name): JEANNE BAILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 TYEE DR SW
TUMWATER WA
98512-7356
US

IV. Provider business mailing address

6005 TYEE DR SW
TUMWATER WA
98512-7356
US

V. Phone/Fax

Practice location:
  • Phone: 707-583-5656
  • Fax:
Mailing address:
  • Phone: 707-583-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP.CP.70108495
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: