Provider Demographics
NPI:1164043741
Name:ZETTLE, KELSEY JO (LCSW)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:JO
Last Name:ZETTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17396 SW JAY ST APT 202
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-7644
Mailing Address - Country:US
Mailing Address - Phone:815-291-3542
Mailing Address - Fax:
Practice Address - Street 1:10200 NE 132ND ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2831
Practice Address - Country:US
Practice Address - Phone:425-898-2359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASA61141511104100000X
ORL141421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker