Healthcare Provider Details

I. General information

NPI: 1417499971
Provider Name (Legal Business Name): JESSICA LAZARO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW GILMAN BLVD SUITE 200
ISSAQUAH WA
98027-5349
US

IV. Provider business mailing address

1700 NW GILMAN BLVD SUITE 200
ISSAQUAH WA
98027-5349
US

V. Phone/Fax

Practice location:
  • Phone: 425-295-7697
  • Fax:
Mailing address:
  • Phone: 425-295-7697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60560580
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: