Provider Demographics
NPI:1447343942
Name:JIRIKOVIC, RAVEN LE
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:LE
Last Name:JIRIKOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 E. MIDVALE RD.
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236
Mailing Address - Country:US
Mailing Address - Phone:888-841-2281
Mailing Address - Fax:
Practice Address - Street 1:105 NW 1ST ST.
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239
Practice Address - Country:US
Practice Address - Phone:360-682-4052
Practice Address - Fax:360-678-3636
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00029629101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health