Provider Demographics
NPI:1578185112
Name:IREDALE, JENNY LYNN (CP 61190077)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
Last Name:IREDALE
Suffix:
Gender:F
Credentials:CP 61190077
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3818
Mailing Address - Country:US
Mailing Address - Phone:360-477-4790
Mailing Address - Fax:360-477-4798
Practice Address - Street 1:825 E 5TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3818
Practice Address - Country:US
Practice Address - Phone:360-477-4790
Practice Address - Fax:360-477-4798
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-16
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60969949101YA0400X
WA61190077101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)