Provider Demographics
NPI:1124693841
Name:BRUNSCH, JAMIE (LICSW)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BRUNSCH
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:NOLTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:516 HIDDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-1452
Mailing Address - Country:US
Mailing Address - Phone:360-901-6064
Mailing Address - Fax:
Practice Address - Street 1:9105 NE HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8961
Practice Address - Country:US
Practice Address - Phone:360-576-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102486101YM0800X
WALW.614995801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health