Healthcare Provider Details

I. General information

NPI: 1861962102
Provider Name (Legal Business Name): JESSICA MARIE BROCKMAN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3438 S 148TH ST
TUKWILA WA
98168-4319
US

IV. Provider business mailing address

4526 FEDERAL AVE
EVERETT WA
98203-2132
US

V. Phone/Fax

Practice location:
  • Phone: 206-832-8518
  • Fax:
Mailing address:
  • Phone: 425-349-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSC61082521
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: