Healthcare Provider Details

I. General information

NPI: 1144379553
Provider Name (Legal Business Name): JONI BENNETT MSW LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 MAIN AVE S
NORTH BEND WA
98045
US

IV. Provider business mailing address

10765 14TH AVE SW APT G5
SEATTLE WA
98146-2166
US

V. Phone/Fax

Practice location:
  • Phone: 425-333-5426
  • Fax: 425-333-5428
Mailing address:
  • Phone: 425-333-5425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberRC00031900
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: