Provider Demographics
NPI:1497444269
Name:DRENNEN, JACK DAVID
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DAVID
Last Name:DRENNEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98577-2503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 6TH ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-2503
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician