Provider Demographics
NPI:1235293473
Name:SPOKANE PSYCHIATRIC CLINIC PS
Entity Type:Organization
Organization Name:SPOKANE PSYCHIATRIC CLINIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JERENE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROCKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-455-9090
Mailing Address - Street 1:105 W 8TH AVE
Mailing Address - Street 2:6055
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204
Mailing Address - Country:US
Mailing Address - Phone:509-455-9090
Mailing Address - Fax:509-747-2118
Practice Address - Street 1:105 W 8TH AVE
Practice Address - Street 2:6055
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-455-9090
Practice Address - Fax:509-747-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000177752084P0800X
WAMD000197752084P0800X
WAMD000180062084P0800X
WAMD000214972084P0800X
WAMD000158372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1077791Medicaid
WA1077817Medicaid
0034874OtherL & I
WA1077775Medicaid
WA1080191Medicaid
WA1077783Medicaid
A07206Medicare UPIN
A07099Medicare UPIN
WA1077791Medicaid
A07128Medicare UPIN
WA1080191Medicaid