Provider Demographics
NPI:1346711744
Name:FAJAR, AKIRA
Entity Type:Individual
Prefix:
First Name:AKIRA
Middle Name:
Last Name:FAJAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 SW 155TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-4417
Mailing Address - Country:US
Mailing Address - Phone:701-541-5279
Mailing Address - Fax:
Practice Address - Street 1:2600 SW HOLDEN ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3505
Practice Address - Country:US
Practice Address - Phone:206-933-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health