Provider Demographics
NPI:1184726754
Name:JAFFE, ROBERTA SUSAN (ACSW, BCD, LICSW)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:SUSAN
Last Name:JAFFE
Suffix:
Gender:F
Credentials:ACSW, BCD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7816
Mailing Address - Country:US
Mailing Address - Phone:360-733-9458
Mailing Address - Fax:775-249-6907
Practice Address - Street 1:119 N COMMERCIAL ST STE 375
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4467
Practice Address - Country:US
Practice Address - Phone:360-738-8806
Practice Address - Fax:775-249-6907
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000050641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB19850Medicare ID - Type Unspecified