Provider Demographics
NPI:1578295101
Name:MEDINA, JASON PHILIP (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PHILIP
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9057 GREENWOOD AVE N STE C205
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3685
Mailing Address - Country:US
Mailing Address - Phone:206-659-0519
Mailing Address - Fax:
Practice Address - Street 1:9057 GREENWOOD AVE N STE C205
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-3685
Practice Address - Country:US
Practice Address - Phone:206-659-0519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011166101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health