Provider Demographics
NPI:1972108744
Name:POULSON, JESSICA CLAUS
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CLAUS
Last Name:POULSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 1/2 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-1434
Mailing Address - Country:US
Mailing Address - Phone:360-270-1929
Mailing Address - Fax:
Practice Address - Street 1:325 1/2 16TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1434
Practice Address - Country:US
Practice Address - Phone:360-270-1929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant