Provider Demographics
NPI:1336515964
Name:DUNLAP, JEREMIAH SHANE (SUDP)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:SHANE
Last Name:DUNLAP
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 108TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3724
Mailing Address - Country:US
Mailing Address - Phone:253-544-4772
Mailing Address - Fax:253-276-0042
Practice Address - Street 1:4909 108TH ST SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3724
Practice Address - Country:US
Practice Address - Phone:253-544-4772
Practice Address - Fax:253-276-0042
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60556714101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60556714OtherCHEMICAL DEPENDANCY PROFESSIONAL
WA41614Medicaid