Basic Information
| Provider Information | |||||||||
| NPI: | 1841700333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JERAISEH | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | LMFTA, CMHS, EMMHS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JERAISEH | ||||||||
| OtherFirstName: | DAVID | ||||||||
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| OtherCredential: | LMFTA, CMHS, EMMHS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2600 SW HOLDEN ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981263505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069729339 | ||||||||
| FaxNumber: | 2069337297 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 W HARRISON ST STE 109 | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980324403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538569000 | ||||||||
| FaxNumber: | 2535206647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2017 | ||||||||
| LastUpdateDate: | 10/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MG60811385 | WA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.