Provider Demographics
NPI:1457181604
Name:LESSEOS, JENNIFER (MG61540850)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LESSEOS
Suffix:
Gender:F
Credentials:MG61540850
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SE 124TH AVE # 24
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6015
Mailing Address - Country:US
Mailing Address - Phone:360-217-9050
Mailing Address - Fax:
Practice Address - Street 1:108 SE 124TH AVE # 24
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6015
Practice Address - Country:US
Practice Address - Phone:360-217-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61540850106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist