Basic Information
Provider Information
NPI: 1457828774
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PORTER
FirstName: JESSICA
MiddleName: RAY
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 325 E PIONEER
Address2:  
City: PUYALLUP
State: WA
PostalCode: 983723265
CountryCode: US
TelephoneNumber: 2536978400
FaxNumber: 2536993730
Practice Location
Address1: 325 E PIONEER
Address2:  
City: PUYALLUP
State: WA
PostalCode: 983723265
CountryCode: US
TelephoneNumber: 2536978400
FaxNumber: 2536993730
Other Information
ProviderEnumerationDate: 10/24/2018
LastUpdateDate: 10/24/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400XCO60778975WAY Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

No ID Information.


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