Provider Demographics
NPI:1073831038
Name:STEPHENS, DEBRA JO (LMP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JO
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-8912
Mailing Address - Country:US
Mailing Address - Phone:360-931-6620
Mailing Address - Fax:
Practice Address - Street 1:3950 BIRCH ST
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-8912
Practice Address - Country:US
Practice Address - Phone:360-931-6620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60138699174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist