Provider Demographics
NPI:1508098930
Name:STICKLEY, JESSICA LYNN (MS, MHP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:STICKLEY
Suffix:
Gender:F
Credentials:MS, MHP
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 579
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-0579
Mailing Address - Country:US
Mailing Address - Phone:366-669-6009
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-414-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60149118101YA0400X
WARC60089841101YP2500X
WACG60158326101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional