Provider Demographics
NPI:1790256527
Name:TALLY, JACK PAUL
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:PAUL
Last Name:TALLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COLUMBIA WELLNESS
Mailing Address - Street 2:PO BOX 1847
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-353-9369
Mailing Address - Fax:360-577-0187
Practice Address - Street 1:2700 SIMPSON AVE
Practice Address - Street 2:STE 01
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520
Practice Address - Country:US
Practice Address - Phone:360-612-0012
Practice Address - Fax:360-577-0187
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61411928101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor