Healthcare Provider Details

I. General information

NPI: 1609651793
Provider Name (Legal Business Name): JAYSON CONNELL COUNSELOR AFFILIATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5197 NW LOWER RIVER ROAD BUILDING #1
VANCOUVER WA
98660
US

IV. Provider business mailing address

3100 SE 168TH AVE APT 196
VANCOUVER WA
98683-2119
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8246
  • Fax:
Mailing address:
  • Phone: 360-643-3091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: