Healthcare Provider Details

I. General information

NPI: 1750214300
Provider Name (Legal Business Name): JESSE STILLWAUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11900 BEACON AVE S
SEATTLE WA
98178-2811
US

IV. Provider business mailing address

11900 BEACON AVE S
SEATTLE WA
98178-2811
US

V. Phone/Fax

Practice location:
  • Phone: 253-325-9077
  • Fax:
Mailing address:
  • Phone: 253-325-9077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: