Provider Demographics
NPI:1871855221
Name:BOMBERGER, JENNIFER LEE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:BOMBERGER
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 1:402 ALLISON WAY
Mailing Address - Street 2:
Mailing Address - City:GOLDENDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98620-9231
Mailing Address - Country:US
Mailing Address - Phone:541-910-2932
Mailing Address - Fax:
Practice Address - Street 1:915 S COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:GOLDENDALE
Practice Address - State:WA
Practice Address - Zip Code:98620-9068
Practice Address - Country:US
Practice Address - Phone:541-910-2932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WALH60650503101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program