Healthcare Provider Details

I. General information

NPI: 1104763481
Provider Name (Legal Business Name): JACKSON IRVING MICHENER LMHCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 6TH AVE NE APT 101
SEATTLE WA
98115-8613
US

IV. Provider business mailing address

7201 6TH AVE NE APT 101
SEATTLE WA
98115-8613
US

V. Phone/Fax

Practice location:
  • Phone: 763-482-3013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.61691478
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: