Provider Demographics
NPI:1528434164
Name:JERALD, SUSAN (MA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JERALD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 W SUNRISE PR NW
Mailing Address - Street 2:
Mailing Address - City:BENTON CITY
Mailing Address - State:WA
Mailing Address - Zip Code:99320-8652
Mailing Address - Country:US
Mailing Address - Phone:509-366-6097
Mailing Address - Fax:509-271-4471
Practice Address - Street 1:2205 W WOODIN AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-9310
Practice Address - Country:US
Practice Address - Phone:509-366-6097
Practice Address - Fax:509-271-4471
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60170431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health