Healthcare Provider Details

I. General information

NPI: 1487476909
Provider Name (Legal Business Name): JANNAH KOETJE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6409 E MILL PLAIN BLVD
VANCOUVER WA
98661-7454
US

IV. Provider business mailing address

4351 COOK UNDERWOOD RD
BINGEN WA
98605-9035
US

V. Phone/Fax

Practice location:
  • Phone: 360-718-8376
  • Fax:
Mailing address:
  • Phone: 360-480-0989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB61626953
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: