Provider Demographics
NPI:1629527718
Name:WADIAK, JEANIE NICOLE (CDPT, MHCA)
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:NICOLE
Last Name:WADIAK
Suffix:
Gender:F
Credentials:CDPT, MHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31208 NE 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-2304
Mailing Address - Country:US
Mailing Address - Phone:360-750-9588
Mailing Address - Fax:360-750-9718
Practice Address - Street 1:2924 FALK RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-5604
Practice Address - Country:US
Practice Address - Phone:360-750-9588
Practice Address - Fax:360-750-9718
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60532732101YA0400X
WACO60404199101YA0400X
WAMC60521887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health