Provider Demographics
NPI:1679262984
Name:NGUYEN, JONATHAN PHU-TRUNG (REV)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PHU-TRUNG
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:REV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 59TH AVE W
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8571
Mailing Address - Country:US
Mailing Address - Phone:253-228-5317
Mailing Address - Fax:
Practice Address - Street 1:9100 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2427
Practice Address - Country:US
Practice Address - Phone:253-302-3826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y99995L101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)