Provider Demographics
NPI:1568732816
Name:RENN, JACKIE M
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:M
Last Name:RENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:RENN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1600 E OLIVE ST
Mailing Address - Street 2:SOUND MENTAL HEALTH
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2735
Mailing Address - Country:US
Mailing Address - Phone:206-302-2200
Mailing Address - Fax:206-302-2210
Practice Address - Street 1:505 29TH ST SE
Practice Address - Street 2:SOUND MENTAL HEALTH
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-7541
Practice Address - Country:US
Practice Address - Phone:253-876-7650
Practice Address - Fax:253-876-7651
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60174469101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor