Healthcare Provider Details

I. General information

NPI: 1346711744
Provider Name (Legal Business Name): AKIRA FAJAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 SW HOLDEN ST
SEATTLE WA
98126-3505
US

IV. Provider business mailing address

432 SW 155TH ST APT A
BURIEN WA
98166-4417
US

V. Phone/Fax

Practice location:
  • Phone: 206-933-7200
  • Fax:
Mailing address:
  • Phone: 701-541-5279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: