Provider Demographics
NPI:1033801717
Name:PAULSON, AMY JENCINA (CG61113130)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JENCINA
Last Name:PAULSON
Suffix:
Gender:F
Credentials:CG61113130
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JENCINA
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3436 MARY ELDER RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 SAWALL AVE W APT 2
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9208
Practice Address - Country:US
Practice Address - Phone:360-623-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61113130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health