Provider Demographics
NPI:1932101581
Name:ANGELL-ERICKSON, JIMMYE DELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JIMMYE
Middle Name:DELL
Last Name:ANGELL-ERICKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JIMMYE
Other - Middle Name:DELL
Other - Last Name:ANGELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1424 E ISAACS AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2154
Mailing Address - Country:US
Mailing Address - Phone:509-529-0410
Mailing Address - Fax:509-527-0751
Practice Address - Street 1:1424 E ISAACS AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2154
Practice Address - Country:US
Practice Address - Phone:509-529-0410
Practice Address - Fax:509-527-0751
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPSY00000304103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA001300005Medicare ID - Type Unspecified