Provider Demographics
NPI:1194947689
Name:CLABORN, JESSICA RAE (LMP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RAE
Last Name:CLABORN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:EVERSON
Mailing Address - State:WA
Mailing Address - Zip Code:98247-0520
Mailing Address - Country:US
Mailing Address - Phone:360-966-2700
Mailing Address - Fax:360-966-2700
Practice Address - Street 1:111 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247
Practice Address - Country:US
Practice Address - Phone:360-966-2700
Practice Address - Fax:360-966-2701
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0213521OtherDEPT. OF L&I