Provider Demographics
NPI:1639843782
Name:EDMISTER, JEANETTE LYNN (MA)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:LYNN
Last Name:EDMISTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 NE 154TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-1410
Mailing Address - Country:US
Mailing Address - Phone:360-513-2835
Mailing Address - Fax:
Practice Address - Street 1:3606 MAIN ST
Practice Address - Street 2:STE 202
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2235
Practice Address - Country:US
Practice Address - Phone:360-619-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61130661101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health