Basic Information
| Provider Information | |||||||||
| NPI: | 1144392325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENISSEN | ||||||||
| FirstName: | ANIEZKA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC, CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2429 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986328486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603539494 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 922 FIR ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603539422 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH60706894 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | CP60067928 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.