Provider Demographics
NPI:1114654225
Name:BANG, JEREMY TYSON (RN, DNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:TYSON
Last Name:BANG
Suffix:
Gender:M
Credentials:RN, DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 WASHINGTON AVE S
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5709
Practice Address - Country:US
Practice Address - Phone:253-833-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60968949163WC1500X
WAAP61330216363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health