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General NPI Number Information
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NPI Number | 1114391349
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Entity Type | Individual
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Provider Name | JEREMY KUTZKE
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Gender | Male
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Dates
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Enumeration Date | 11/27/2015
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Last Update Date | 01/23/2017
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Provider Practice Location Address
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Address Line | 6400 SOUTHCENTER BLVD
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City | TUKWILA
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State | WA
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Zip | 98188-2547
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Country | US
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Telephone | 206-444-7800
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Fax |
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Provider Business Mailing Address
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Address Line | 11526 30TH AVE NE
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City | SEATTLE
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State | WA
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Zip | 98125-6861
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Country | US
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Telephone | 425-941-4222
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | CG60574492
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License Number State | WA
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