Healthcare Provider Details

I. General information

NPI: 1477036739
Provider Name (Legal Business Name): MR. JONATHAN JACOB HIETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. JONNY JACOB HIETT

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ELLIOTT AVE W STE 500
SEATTLE WA
98119-4292
US

IV. Provider business mailing address

4904 13TH AVE S
SEATTLE WA
98108-1825
US

V. Phone/Fax

Practice location:
  • Phone: 206-708-6432
  • Fax: 206-323-2184
Mailing address:
  • Phone: 303-862-0766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61384297
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: