Provider Demographics
NPI:1275026577
Name:ASHMORE, JENELLE LYNN
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:LYNN
Last Name:ASHMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 451
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321-0451
Mailing Address - Country:US
Mailing Address - Phone:909-993-4043
Mailing Address - Fax:
Practice Address - Street 1:22526 SE 64TH PL STE 210
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5368
Practice Address - Country:US
Practice Address - Phone:190-999-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARBT-17-36067106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician