Provider Demographics
NPI:1104486158
Name:YOUNGQUIST, JODI MARIE (LMHCA)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:MARIE
Last Name:YOUNGQUIST
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 19TH ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-7123
Mailing Address - Country:US
Mailing Address - Phone:253-205-5807
Mailing Address - Fax:
Practice Address - Street 1:11102 SUNRISE BLVD E STE 100
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8846
Practice Address - Country:US
Practice Address - Phone:253-205-5807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60881855101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60881855OtherWASHINGTON STATE DEPARTMENT OF HEALTH