Provider Demographics
NPI:1790401339
Name:MINCKLEY, JESSICA L (LMHC, ATR-P)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:MINCKLEY
Suffix:
Gender:F
Credentials:LMHC, ATR-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 NE 97TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2126
Mailing Address - Country:US
Mailing Address - Phone:503-926-0081
Mailing Address - Fax:
Practice Address - Street 1:536 NE 97TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2126
Practice Address - Country:US
Practice Address - Phone:503-926-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61327714101YM0800X
ATRP22455221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health