MEDICARE: SUZANNA ROSE JAMISON LISCWA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SX61403122	WA

General Provider Information

NPI Number	:	1639937329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNA ROSE JAMISON LISCWA

Provider Business Mailing Address
First Line	:	8304 NE 136TH AVE
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98682-3376
Country	:	US
Telephone Number	:	360-771-9099
Fax Number	:

Provider Business Practice Location Address
First Line	:	8304 NE 136TH AVE
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98682-3376
Country	:	US
Telephone Number	:	360-771-9099
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2024
Last Update Date	:	03/16/2024

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