Provider Demographics
NPI:1770866097
Name:VICTOR, JASON M (LMFT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:VICTOR
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W GOWE ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5892
Mailing Address - Country:US
Mailing Address - Phone:253-205-0561
Mailing Address - Fax:253-735-9974
Practice Address - Street 1:33301 1ST WAY S
Practice Address - Street 2:SUITE C-115
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6252
Practice Address - Country:US
Practice Address - Phone:253-205-0561
Practice Address - Fax:253-735-9974
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60210247101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health