Healthcare Provider Details

I. General information

NPI: 1841154127
Provider Name (Legal Business Name): JILLIAN MASAKO MITSUDA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34600 12TH AVE SW
FEDERAL WAY WA
98023-7060
US

IV. Provider business mailing address

34816 1ST AVE S APT A515
FEDERAL WAY WA
98003-6983
US

V. Phone/Fax

Practice location:
  • Phone: 253-945-3804
  • Fax:
Mailing address:
  • Phone: 253-945-3804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number610329E
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: