Healthcare Provider Details

I. General information

NPI: 1215576152
Provider Name (Legal Business Name): ROGER JONATHAN GAULT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2212 S JACKSON ST
SEATTLE WA
98144-2591
US

IV. Provider business mailing address

1305 TACOMA AVE S STE 305
TACOMA WA
98402-1903
US

V. Phone/Fax

Practice location:
  • Phone: 206-322-2387
  • Fax:
Mailing address:
  • Phone: 253-396-5827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: