Provider Demographics
NPI:1639505605
Name:DOUGLASS, JESSICA EDLUND (BA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:EDLUND
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660
Mailing Address - Country:US
Mailing Address - Phone:360-695-1014
Mailing Address - Fax:360-750-1374
Practice Address - Street 1:1014 MAIN STREET
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660
Practice Address - Country:US
Practice Address - Phone:360-695-1014
Practice Address - Fax:360-750-1374
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-22
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program