Provider Demographics
NPI:1649671504
Name:AMBURGEY, JO NELL
Entity type:Individual
Prefix:
First Name:JO NELL
Middle Name:
Last Name:AMBURGEY
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:PO BOX 513
Mailing Address - Street 2:
Mailing Address - City:KETTLE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99141-0513
Mailing Address - Country:US
Mailing Address - Phone:509-675-0642
Mailing Address - Fax:509-738-2561
Practice Address - Street 1:298 S MAIN ST
Practice Address - Street 2:SUITE L3
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2447
Practice Address - Country:US
Practice Address - Phone:509-675-0642
Practice Address - Fax:509-738-2561
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000079121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE