Healthcare Provider Details

I. General information

NPI: 1629964200
Provider Name (Legal Business Name): JENNIFER NICOLA CICCARELLI MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21701 76TH AVE W STE 301
EDMONDS WA
98026-7500
US

IV. Provider business mailing address

21701 76TH AVE W STE 301
EDMONDS WA
98026-7500
US

V. Phone/Fax

Practice location:
  • Phone: 425-800-5692
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSC70019535
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: