Provider Demographics
NPI:1508232919
Name:DEARBORN, JODY
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:DEARBORN
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 1:2208 NW MARKET ST STE 430D
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4161
Mailing Address - Country:US
Mailing Address - Phone:844-733-5262
Mailing Address - Fax:
Practice Address - Street 1:2208 NW MARKET ST STE 430D
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4161
Practice Address - Country:US
Practice Address - Phone:844-733-5262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60536007101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health