Provider Demographics
NPI:1811566409
Name:DE LARWELLE, JESSICA A (MSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:DE LARWELLE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3832
Mailing Address - Country:US
Mailing Address - Phone:425-261-1500
Mailing Address - Fax:425-261-1515
Practice Address - Street 1:2930 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3832
Practice Address - Country:US
Practice Address - Phone:425-261-1500
Practice Address - Fax:425-261-1515
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2023-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8707-123101YM0800X
WALW60877309104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUNKNOWNMedicaid