Provider Demographics
NPI:1437893096
Name:TIEDE, JESSICA AVERY
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:AVERY
Last Name:TIEDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 164TH ST SW APT 1705
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-3252
Mailing Address - Country:US
Mailing Address - Phone:425-367-1753
Mailing Address - Fax:
Practice Address - Street 1:4030 LAKE WASHINGTON BLVD NE STE 201
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-7870
Practice Address - Country:US
Practice Address - Phone:425-200-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health