Provider Demographics
NPI:1336478254
Name:DAVIS, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:DAVIS
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 6956
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-6956
Mailing Address - Country:US
Mailing Address - Phone:307-413-2457
Mailing Address - Fax:
Practice Address - Street 1:46 IRON HORSE DR
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:WY
Practice Address - Zip Code:83128-8101
Practice Address - Country:US
Practice Address - Phone:307-413-2457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-24
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY622101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)