1982240313 NPI number — KAITLIN JEAN CLEMENTS JENKINS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982240313 NPI number — KAITLIN JEAN CLEMENTS JENKINS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS
Provider First Name:
KAITLIN
Provider Middle Name:
JEAN CLEMENTS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLEMENTS
Provider Other First Name:
KAITLIN
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982240313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
COLUMBIA WELLNESS
Provider Second Line Business Mailing Address:
720 14TH AVE
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-353-9396
Provider Business Mailing Address Fax Number:
360-577-0187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
COLUMBIA WELLNESS
Provider Second Line Business Practice Location Address:
720 14TH AVE
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-567-2211
Provider Business Practice Location Address Fax Number:
360-577-0187
Provider Enumeration Date:
11/20/2019

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: 101YM0800X , with the licence number:  CG61023510 , 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)