Provider Demographics
NPI:1841563798
Name:JACK, JOY ELAINE (CDP)
Entity Type:Individual
Prefix:MRS
First Name:JOY
Middle Name:ELAINE
Last Name:JACK
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:MS
Other - First Name:JOY
Other - Middle Name:ELAINE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDP
Mailing Address - Street 1:24116 102ND PL W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-5716
Mailing Address - Country:US
Mailing Address - Phone:206-801-7399
Mailing Address - Fax:
Practice Address - Street 1:1412 140TH PL NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3915
Practice Address - Country:US
Practice Address - Phone:425-747-7892
Practice Address - Fax:425-747-8348
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 00002626101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)