Healthcare Provider Details

I. General information

NPI: 1548175292
Provider Name (Legal Business Name): MAGNOLIA MENTAL HEALTH WASHINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

12207 NE 8TH ST
BELLEVUE WA
98005-3113
US

IV. Provider business mailing address

12207 NE 8TH ST
BELLEVUE WA
98005-3113
US

V. Phone/Fax

Practice location:
  • Phone: 425-441-3589
  • Fax:
Mailing address:
  • Phone: 425-441-3589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACK BRENNAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 425-441-3589