Healthcare Provider Details

I. General information

NPI: 1275038598
Provider Name (Legal Business Name): JESSE PAULSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E EDGAR ST
SEATTLE WA
98102-3132
US

IV. Provider business mailing address

1841 23RD AVE E
SEATTLE WA
98112-2913
US

V. Phone/Fax

Practice location:
  • Phone: 206-809-7436
  • Fax:
Mailing address:
  • Phone: 781-608-0010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD61076434
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD61076434
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: