Provider Demographics
NPI:1346962974
Name:LYDSTON, JACQUELINE ANNA
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANNA
Last Name:LYDSTON
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 1:400 E EVERGREEN BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3264
Mailing Address - Country:US
Mailing Address - Phone:360-977-9679
Mailing Address - Fax:
Practice Address - Street 1:400 E EVERGREEN BLVD STE 213
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3264
Practice Address - Country:US
Practice Address - Phone:360-977-9679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC613452381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical