Basic Information
| Provider Information | |||||||||
| NPI: | 1497281067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECKER | ||||||||
| FirstName: | JENNY | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1016 TACOMA AVE | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989442263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098371500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1016 TACOMA AVE | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989442263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098371500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2017 | ||||||||
| LastUpdateDate: | 05/02/2017 | ||||||||
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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 | 101YA0400X | LW60729485 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | LW60729485 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.