Provider Demographics
NPI:1487476909
Name:KOETJE, JANNAH
Entity type:Individual
Prefix:
First Name:JANNAH
Middle Name:
Last Name:KOETJE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4351 COOK UNDERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BINGEN
Mailing Address - State:WA
Mailing Address - Zip Code:98605-9035
Mailing Address - Country:US
Mailing Address - Phone:360-480-0989
Mailing Address - Fax:
Practice Address - Street 1:6409 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7454
Practice Address - Country:US
Practice Address - Phone:360-718-8376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-26
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61626953106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician