Provider Demographics
NPI:1043767049
Name:MANDIN, JENNIFER ALICE (LCISW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALICE
Last Name:MANDIN
Suffix:
Gender:F
Credentials:LCISW
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:MCCLELLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:
Practice Address - Street 1:124 E SHORT AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1555
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60930980390200000X
WALW61307762104100000X
WASC610034121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical