1962541151 NPI number — MS. JEREMY ROSSA COLE LCSW

Table of content: MS. JEREMY ROSSA COLE LCSW (NPI 1962541151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962541151 NPI number — MS. JEREMY ROSSA COLE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLE
Provider First Name:
JEREMY
Provider Middle Name:
ROSSA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962541151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18511 HARRIS AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUQUAMISH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98392-9697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-797-3434
Provider Business Mailing Address Fax Number:
360-930-0957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19045 STATE HIGHWAY 305 NE STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POULSBO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-930-0615
Provider Business Practice Location Address Fax Number:
360-598-3235
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 034373 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7194211 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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