MEDICARE: JESSICA L MINCKLEY LMHC, ATR-P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	221700000X	Art Therapist	22455
2	101YM0800X	Mental Health Counselor	LH61457229	WA

General Provider Information

NPI Number	:	1790401339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA L MINCKLEY LMHC, ATR-P

Provider Business Mailing Address
First Line	:	3512 LA CLEDE AVE APT 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1950
Country	:	US
Telephone Number	:	503-926-0081
Fax Number	:

Provider Business Practice Location Address
First Line	:	536 NE 97TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-2126
Country	:	US
Telephone Number	:	503-926-0081
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2022
Last Update Date	:	06/06/2026

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