Provider Demographics
NPI:1629463617
Name:JETT, LOLA (SUDP)
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:JETT
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 WETMORE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2927
Mailing Address - Country:US
Mailing Address - Phone:425-258-5270
Mailing Address - Fax:
Practice Address - Street 1:16715 AURORA AVE N # 102
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5310
Practice Address - Country:US
Practice Address - Phone:206-546-9766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60763564101YA0400X
WACP60763564101YA0400X
WACO 60521530101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)