Provider Demographics
NPI:1316082530
Name:RIVERA, JENNIFER JEWLYNN
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JEWLYNN
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:JEWLYNN
Other - Last Name:HOOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-0907
Mailing Address - Country:US
Mailing Address - Phone:509-775-3583
Mailing Address - Fax:
Practice Address - Street 1:42 KLONDIKE RD
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166-9701
Practice Address - Country:US
Practice Address - Phone:509-775-3341
Practice Address - Fax:509-775-8906
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00056567101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health