Provider Demographics
NPI:1952573974
Name:DELASTRADA, JEAN GANT (MED, MA)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:GANT
Last Name:DELASTRADA
Suffix:
Gender:F
Credentials:MED, MA
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 2827
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-2827
Mailing Address - Country:US
Mailing Address - Phone:206-501-9404
Mailing Address - Fax:
Practice Address - Street 1:1516 DECATUR ST SW
Practice Address - Street 2:UNIT 130
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5848
Practice Address - Country:US
Practice Address - Phone:206-501-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00025709101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARC00025709OtherREGISTERED COUNSELOR