Provider Demographics
NPI:1376986174
Name:WASHBISH, JACKIE ELAINE (SUDP)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:ELAINE
Last Name:WASHBISH
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:ELAINE
Other - Last Name:RASMUSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:904 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-4324
Mailing Address - Country:US
Mailing Address - Phone:360-856-6300
Mailing Address - Fax:504-209-7048
Practice Address - Street 1:904 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4324
Practice Address - Country:US
Practice Address - Phone:360-856-6300
Practice Address - Fax:564-209-7048
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
WACP60708363101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2265964Medicaid