Healthcare Provider Details

I. General information

NPI: 1609485242
Provider Name (Legal Business Name): JILL JACQUELINE LOCKE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 25TH AVE NE
SEATTLE WA
98105-4107
US

IV. Provider business mailing address

5526 34TH AVE NE
SEATTLE WA
98105-2305
US

V. Phone/Fax

Practice location:
  • Phone: 206-987-8080
  • Fax:
Mailing address:
  • Phone: 818-384-3554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number60919089
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: