Provider Demographics
NPI:1891984498
Name:IANNICIELLO, JEWELYA M (MSW, CDP)
Entity Type:Individual
Prefix:
First Name:JEWELYA
Middle Name:M
Last Name:IANNICIELLO
Suffix:
Gender:F
Credentials:MSW, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 55TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-3156
Mailing Address - Country:US
Mailing Address - Phone:206-406-1178
Mailing Address - Fax:
Practice Address - Street 1:3402 55TH AVE NE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98422-3156
Practice Address - Country:US
Practice Address - Phone:206-406-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005115101YA0400X
WARC00042019101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)