Provider Demographics
NPI:1750853057
Name:MEHL, JAKE ALEX (SUDP)
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:ALEX
Last Name:MEHL
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:MEHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUDP
Mailing Address - Street 1:2732 GRAND AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3416
Mailing Address - Country:US
Mailing Address - Phone:206-940-0867
Mailing Address - Fax:
Practice Address - Street 1:2732 GRAND AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3416
Practice Address - Country:US
Practice Address - Phone:425-258-2407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
261QR0405X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124159157OtherEVERGREEN RECOVERY CENTER