Healthcare Provider Details

I. General information

NPI: 1902388317
Provider Name (Legal Business Name): JORDAN STABLES LMHCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16150 NE 85TH ST STE 220
REDMOND WA
98052-3546
US

IV. Provider business mailing address

16150 NE 85TH ST STE 220
REDMOND WA
98052-3546
US

V. Phone/Fax

Practice location:
  • Phone: 425-558-0558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number60885269
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: