Provider Demographics
NPI:1568188183
Name:TICE-BORDEN, JERRI (MA)
Entity Type:Individual
Prefix:
First Name:JERRI
Middle Name:
Last Name:TICE-BORDEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JERRI
Other - Middle Name:A
Other - Last Name:TICE-BORDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BORDEN
Mailing Address - Street 1:2041 E MADISON ST
Mailing Address - Street 2:SEATTLE BACK CLINIC/WELLNESS CENTER/SILENCE FEARS
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2959
Mailing Address - Country:US
Mailing Address - Phone:206-446-0522
Mailing Address - Fax:
Practice Address - Street 1:2041 E MADISON ST
Practice Address - Street 2:SEATTLE BACK CLINIC/WELLNESS CENTER/SILENCE FEARS
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-2959
Practice Address - Country:US
Practice Address - Phone:206-446-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-14
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61370242101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMHCA.MC.61370242Medicaid