Provider Demographics
NPI:1730534272
Name:JENNIFER BROOKE SJOSTROM
Entity type:Organization
Organization Name:JENNIFER BROOKE SJOSTROM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:SJOSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-691-1174
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0129
Mailing Address - Country:US
Mailing Address - Phone:208-691-1174
Mailing Address - Fax:208-247-8513
Practice Address - Street 1:4407 N DIVISION ST STE 603
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1660
Practice Address - Country:US
Practice Address - Phone:208-467-4931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4347101YM0800X
WALH00007832101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty