Basic Information
| Provider Information | |||||||||
| NPI: | 1417512617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | EUN-BIN | ||||||||
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| OtherLastName: | AN | ||||||||
| OtherFirstName: | JACKIE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1323 BOREN AVE APT 513 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981013714 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3639 MARTIN LUTHER KING JR WAY S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981446847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066957600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | WA | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.