Provider Demographics
NPI:1689232639
Name:JULES, ELISSA CHARLENE (CP61224601)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:CHARLENE
Last Name:JULES
Suffix:
Gender:F
Credentials:CP61224601
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 31ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-7423
Mailing Address - Country:US
Mailing Address - Phone:360-716-2200
Mailing Address - Fax:360-716-2211
Practice Address - Street 1:6330 31ST AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-7423
Practice Address - Country:US
Practice Address - Phone:360-716-2200
Practice Address - Fax:360-716-2211
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60902535101YA0400X
WACP61224601101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)