Provider Demographics
NPI:1336515964
Name:DUNLAP, JEREMIAH SHANE (SUDP)
Entity type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:SHANE
Last Name:DUNLAP
Suffix:
Gender:
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18208 113TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8854
Mailing Address - Country:US
Mailing Address - Phone:253-359-3219
Mailing Address - Fax:
Practice Address - Street 1:18208 113TH AVE E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8854
Practice Address - Country:US
Practice Address - Phone:253-359-3219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60556714101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60556714OtherCHEMICAL DEPENDANCY PROFESSIONAL
WA41614Medicaid