Basic Information
| Provider Information | |||||||||
| NPI: | 1578185112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IREDALE | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | CP 61190077 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604774790 | ||||||||
| FaxNumber: | 3604774798 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604774790 | ||||||||
| FaxNumber: | 3604774798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2020 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 60969949 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 61190077 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.