Healthcare Provider Details

I. General information

NPI: 1952463234
Provider Name (Legal Business Name): JOHN WILLIAM MACK BA, CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17018 15TH AVE NE
SHORELINE WA
98155-5137
US

IV. Provider business mailing address

17018 15TH AVE NE
SHORELINE WA
98155-5137
US

V. Phone/Fax

Practice location:
  • Phone: 206-601-9804
  • Fax:
Mailing address:
  • Phone: 206-601-9804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP 00002940
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60142038
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: