Healthcare Provider Details

I. General information

NPI: 1508260746
Provider Name (Legal Business Name): JENNIFER CROKE PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31919 1ST AVE S 203
FEDERAL WAY WA
98003-5236
US

IV. Provider business mailing address

31919 1ST AVE S 203
FEDERAL WAY WA
98003-5236
US

V. Phone/Fax

Practice location:
  • Phone: 253-839-4172
  • Fax: 206-429-2738
Mailing address:
  • Phone: 253-839-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLW 00009685
License Number StateWA

VIII. Authorized Official

Name: MS. JENNIFER CROKE
Title or Position: PSYCHOTHERAPIST
Credential: LICSW
Phone: 917-975-7712