{
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"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 822441",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "VANCOUVER",
"MailingAddressStateName": "WA",
"MailingAddressPostalCode": "98682-0053",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "360-612-2396",
"MailingAddressFaxNumber": "360-450-4426",
"FirstLinePracticeLocationAddress": "PO BOX 822441",
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"PracticeLocationAddressCityName": "VANCOUVER",
"PracticeLocationAddressStateName": "WA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "360-612-2396",
"PracticeLocationAddressFaxNumber": "360-450-4426",
"EnumerationDate": "09/19/2017",
"LastUpdateDate": "11/26/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DISTEFANO",
"AuthorizedOfficialFirstName": "JENNIFER",
"AuthorizedOfficialMiddleName": "DIAN",
"AuthorizedOfficialTitle": "OWNER/COUNSELOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LMHC",
"AuthorizedOfficialTelephoneNumber": "360-612-2396",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
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}
}