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General NPI Number Information
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NPI Number | 1578231254
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Entity Type | Individual
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Provider Name | JORGE PONCE JR. PHD
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Gender | Male
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Dates
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Enumeration Date | 08/30/2021
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Last Update Date | 07/09/2025
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Provider Practice Location Address
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Address Line | 2000 W MARINE VIEW DR BLDG 2000
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City | EVERETT
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State | WA
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Zip | 98207-2111
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Country | US
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Telephone | 425-304-4697
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Fax |
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Provider Business Mailing Address
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Address Line | 3958 85TH AVE NE
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City | MARYSVILLE
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State | WA
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Zip | 98270-7105
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Country | US
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Telephone |
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810008003
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License Number State | VA
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