Provider Demographics
NPI:1881985240
Name:IVANOV, JENNY (BA)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:IVANOV
Suffix:
Gender:F
Credentials:BA
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 3810
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98213
Mailing Address - Country:US
Mailing Address - Phone:425-349-6826
Mailing Address - Fax:425-349-8348
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98021
Practice Address - Country:US
Practice Address - Phone:425-349-6804
Practice Address - Fax:425-349-6855
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health