Provider Demographics
NPI:1639385578
Name:SAMPSON-SUSAG, JENNIFER MARIA (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIA
Last Name:SAMPSON-SUSAG
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:MARIA
Other - Last Name:SAMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LMFT
Mailing Address - Street 1:621 PACIFIC AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4611
Mailing Address - Country:US
Mailing Address - Phone:253-642-6108
Mailing Address - Fax:206-299-3272
Practice Address - Street 1:621 PACIFIC AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4600
Practice Address - Country:US
Practice Address - Phone:253-642-6108
Practice Address - Fax:206-299-3272
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF 60230886106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist