Healthcare Provider Details

I. General information

NPI: 1558000570
Provider Name (Legal Business Name): JENNIFER GASTELUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 SW 10TH ST
RENTON WA
98057-5223
US

IV. Provider business mailing address

7304 139TH STREET CT E
PUYALLUP WA
98373-8218
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-4880
  • Fax:
Mailing address:
  • Phone: 562-200-6067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61513510
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: