Healthcare Provider Details

I. General information

NPI: 1023950409
Provider Name (Legal Business Name): JILL MARIE MOELLER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 NE BLAKELY DR
ISSAQUAH WA
98029-6201
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 425-313-7000
  • Fax: 425-394-7908
Mailing address:
  • Phone: 206-320-4476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW70095398
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: