Provider Demographics
NPI:1417328998
Name:SEO, JONGWON
Entity Type:Individual
Prefix:
First Name:JONGWON
Middle Name:
Last Name:SEO
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 1:3200 NE 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682
Mailing Address - Country:US
Mailing Address - Phone:360-695-1014
Mailing Address - Fax:360-695-1014
Practice Address - Street 1:3200 NE 109TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682
Practice Address - Country:US
Practice Address - Phone:360-609-1660
Practice Address - Fax:360-695-1014
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WALW611319051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker