Provider Demographics
NPI:1306990551
Name:SHINE, JESSICA NICOLE (PHD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:SHINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:5455 ALMIRA DR SE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8330
Mailing Address - Country:US
Mailing Address - Phone:360-373-5031
Mailing Address - Fax:
Practice Address - Street 1:900 SHERIDAN RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2701
Practice Address - Country:US
Practice Address - Phone:360-415-5866
Practice Address - Fax:360-415-5886
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00054256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health