Healthcare Provider Details

I. General information

NPI: 1639780620
Provider Name (Legal Business Name): JAYNELLE KOPP SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 NE 26TH AVE
VANCOUVER WA
98665-0672
US

IV. Provider business mailing address

PO BOX 2429
LONGVIEW WA
98632-8486
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8228
  • Fax: 360-353-9440
Mailing address:
  • Phone: 360-353-9494
  • Fax: 360-353-9440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10850
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61346560
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: