=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356412183
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYNN MARIE JENNINGS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7825 N SOUND DR
-----------------------------------------------------
City | SEDRO WOOLLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98284-7675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-856-4280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 E COLLEGE WAY STE A PMB 596
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98273-5637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-424-5092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | RC00036015
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------