1285773648 NPI number — DR. JANE SUSAN LARSON REAM PSY.D.

Table of content: DR. JANE SUSAN LARSON REAM PSY.D. (NPI 1285773648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285773648 NPI number — DR. JANE SUSAN LARSON REAM PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON REAM
Provider First Name:
JANE
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LARSON
Provider Other First Name:
JANE
Provider Other Middle Name:
SUSAN
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:
1285773648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3210 SE 156TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-349-6100
Provider Business Mailing Address Fax Number:
503-274-1902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3210 SE 156TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-349-6100
Provider Business Practice Location Address Fax Number:
503-274-1902
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: 103TC0700X , with the licence number:  1796 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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