Provider Demographics
NPI:1760953855
Name:JONES, JACKIELYN T (CDP)
Entity Type:Individual
Prefix:
First Name:JACKIELYN
Middle Name:T
Last Name:JONES
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 DIVISION ST # 19
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4614
Mailing Address - Country:US
Mailing Address - Phone:360-434-8548
Mailing Address - Fax:
Practice Address - Street 1:614 DIVISION ST # 19
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4614
Practice Address - Country:US
Practice Address - Phone:360-434-8548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60640271101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA090515Medicaid