Provider Demographics
NPI:1891984498
Name:IANNICIELLO, JEWELYA M (SUDP, LICSW)
Entity type:Individual
Prefix:
First Name:JEWELYA
Middle Name:M
Last Name:IANNICIELLO
Suffix:
Gender:F
Credentials:SUDP, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 112TH ST E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-5307
Mailing Address - Country:US
Mailing Address - Phone:253-460-0062
Mailing Address - Fax:
Practice Address - Street 1:5001 112TH ST E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98446-5307
Practice Address - Country:US
Practice Address - Phone:253-460-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2025-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW601748631041C0700X
WACP00005115101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty