Healthcare Provider Details

I. General information

NPI: 1003309089
Provider Name (Legal Business Name): LACI JENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11911 NE 1ST ST STE 205
BELLEVUE WA
98005-3056
US

IV. Provider business mailing address

7530B 15TH AVE NW
SEATTLE WA
98117-5453
US

V. Phone/Fax

Practice location:
  • Phone: 971-801-2054
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number61399348
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: