Provider Demographics
NPI:1598858599
Name:JUNGCLAS, LISA A (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:JUNGCLAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BELLWETHER WAY STE 220
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2914
Mailing Address - Country:US
Mailing Address - Phone:360-734-7310
Mailing Address - Fax:360-647-8336
Practice Address - Street 1:12 BELLWETHER WAY STE 220
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2914
Practice Address - Country:US
Practice Address - Phone:360-734-7310
Practice Address - Fax:360-647-8336
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002518103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8884222Medicare UPIN
WAAB39450Medicare ID - Type Unspecified