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General NPI Number Information
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NPI Number | 1174036099
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Entity Type | Organization
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Legal Business Name | FAMILY RESTORATION & EMPOWERMENT ENTERPRISES
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Dates
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Enumeration Date | 11/14/2017
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Last Update Date | 11/14/2017
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Provider Practice Location Address
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Address Line | 1554 S GRANT AVE
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City | TACOMA
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State | WA
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Zip | 98405-3250
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Country | US
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Telephone | 253-365-3964
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Fax |
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Provider Business Mailing Address
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Address Line | 2615 19TH STREET PL SW
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City | PUYALLUP
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State | WA
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Zip | 98373-3953
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Country | US
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Telephone | 253-365-3964
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. MONIQUE RENEE JORDAN
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Credential | LMHC
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Telephone | 253-365-3964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LH60806253
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License Number State | WA
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