Healthcare Provider Details

I. General information

NPI: 1245852524
Provider Name (Legal Business Name): LUTRICIA LEVETTE CISCO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LUTRICIA L JACKSON RN

II. Dates (important events)

Enumeration Date: 05/10/2020
Last Update Date: 05/10/2020
Certification Date: 05/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 UNION AVE SE STE 244
OLYMPIA WA
98501-2060
US

IV. Provider business mailing address

1617 FONES RD SE TRLR 35
OLYMPIA WA
98501-7408
US

V. Phone/Fax

Practice location:
  • Phone: 360-918-7240
  • Fax: 360-459-3705
Mailing address:
  • Phone: 360-999-1910
  • Fax: 360-459-3705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN60086332
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: