Provider Demographics
NPI:1306352182
Name:CANTLON, JENNIFER MARIE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:CANTLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CHIMACUM
Mailing Address - State:WA
Mailing Address - Zip Code:98325-9757
Mailing Address - Country:US
Mailing Address - Phone:360-774-1727
Mailing Address - Fax:
Practice Address - Street 1:5050 CENTER RD
Practice Address - Street 2:
Practice Address - City:CHIMACUM
Practice Address - State:WA
Practice Address - Zip Code:98325-9757
Practice Address - Country:US
Practice Address - Phone:360-774-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-16
Last Update Date:2017-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARBT-15-06598106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty