=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730534272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER BROOKE SJOSTROM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2016
-----------------------------------------------------
Last Update Date | 05/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4407 N DIVISION ST STE 603
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99207-1660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-467-4931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 129
-----------------------------------------------------
City | LIBERTY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99019-0129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-691-1174
-----------------------------------------------------
Fax | 208-247-8513
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MS. JENNIFER BROOKE SJOSTROM
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 208-691-1174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LCPC-4347
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LH00007832
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------