Healthcare Provider Details

I. General information

NPI: 1114654225
Provider Name (Legal Business Name): JEREMY TYSON BANG RN, DNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 WASHINGTON AVE S
KENT WA
98032-5709
US

IV. Provider business mailing address

325 W GOWE ST
KENT WA
98032-5892
US

V. Phone/Fax

Practice location:
  • Phone: 253-833-7444
  • Fax:
Mailing address:
  • Phone: 253-833-7444
  • Fax: 253-661-8631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP.AP.61330216-NP
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.RN.60968949
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: