Provider Demographics
NPI:1710061528
Name:POULSON, MARY JANE (MA, NCC, LMHC, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:POULSON
Suffix:
Gender:F
Credentials:MA, NCC, LMHC, LPC
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:POULSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, NCC, LMHC, LPC
Mailing Address - Street 1:719 JADWIN AVE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4217
Mailing Address - Country:US
Mailing Address - Phone:509-430-8626
Mailing Address - Fax:509-943-2129
Practice Address - Street 1:719 JADWIN AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4217
Practice Address - Country:US
Practice Address - Phone:509-430-8626
Practice Address - Fax:509-943-2129
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005937101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2075572Medicaid