Provider Demographics
NPI:1326546771
Name:KRILEVICH, JAN LEE TRIMBLE (CDPT)
Entity Type:Individual
Prefix:
First Name:JAN LEE
Middle Name:TRIMBLE
Last Name:KRILEVICH
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:JAN LEE
Other - Middle Name:TRIMBLE
Other - Last Name:KILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDPT
Mailing Address - Street 1:6305 189TH PL SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5134
Mailing Address - Country:US
Mailing Address - Phone:425-599-7740
Mailing Address - Fax:
Practice Address - Street 1:2601 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3309
Practice Address - Country:US
Practice Address - Phone:425-322-0810
Practice Address - Fax:425-339-2601
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60781160101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty