Provider Demographics
NPI:1174001341
Name:DILLMAN, JESSICA SUE ROSE (CO60579677)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:SUE ROSE
Last Name:DILLMAN
Suffix:
Gender:F
Credentials:CO60579677
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-1109
Mailing Address - Country:US
Mailing Address - Phone:253-200-0300
Mailing Address - Fax:253-302-8493
Practice Address - Street 1:9720 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4456
Practice Address - Country:US
Practice Address - Phone:253-503-3666
Practice Address - Fax:253-302-8493
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA80-0461504101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA80-0461504Medicaid