Provider Demographics
NPI:1265582654
Name:STILLWAUGH, JODY
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:STILLWAUGH
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 1:2510 BIRCHFIELD RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-9534
Mailing Address - Country:US
Mailing Address - Phone:509-494-9170
Mailing Address - Fax:
Practice Address - Street 1:2510 BIRCHFIELD RD
Practice Address - Street 2:UNIT 1
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-9534
Practice Address - Country:US
Practice Address - Phone:509-494-9170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003749101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)