Provider Demographics
NPI:1578009585
Name:KLEIN, JACQUELINE ELAINE (SUDP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:KLEIN
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 SUMNER AVE STE I
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-4602
Mailing Address - Country:US
Mailing Address - Phone:360-623-0537
Mailing Address - Fax:
Practice Address - Street 1:1812 SUMNER AVE STE I
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4602
Practice Address - Country:US
Practice Address - Phone:360-623-0537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60629237101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)