Provider Demographics
NPI:1043313935
Name:REVAY, JEANETTE GERALDINE (ARNP PSYCH)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:GERALDINE
Last Name:REVAY
Suffix:
Gender:F
Credentials:ARNP PSYCH
Other - Prefix:
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Mailing Address - Street 1:2747 PACIFIC AVE SE
Mailing Address - Street 2:SUITE B19
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501
Mailing Address - Country:US
Mailing Address - Phone:360-481-7477
Mailing Address - Fax:360-491-9357
Practice Address - Street 1:2747 PACIFIC AVE SE
Practice Address - Street 2:SUITE B19
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501
Practice Address - Country:US
Practice Address - Phone:360-481-7477
Practice Address - Fax:360-491-9357
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAP30005089163WP0808X, 363LP0808X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9625682Medicaid
WAGAB19829Medicare ID - Type Unspecified
WA9625682Medicaid