Provider Demographics
NPI:1457129926
Name:CONLEY, JESSE (SUDPT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CONLEY
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 SE 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-6573
Mailing Address - Country:US
Mailing Address - Phone:360-635-3867
Mailing Address - Fax:
Practice Address - Street 1:305 PACIFIC AVE S STE C
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1638
Practice Address - Country:US
Practice Address - Phone:360-644-1027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61334546101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)