Provider Demographics
NPI:1134738222
Name:WALLIS, JONATHAN THOMAS (MA, LMHCA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:THOMAS
Last Name:WALLIS
Suffix:
Gender:M
Credentials:MA, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2569
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98213-0569
Mailing Address - Country:US
Mailing Address - Phone:425-212-4200
Mailing Address - Fax:425-212-4201
Practice Address - Street 1:811 MADISON ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-4543
Practice Address - Country:US
Practice Address - Phone:425-212-4200
Practice Address - Fax:425-212-4201
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WA61188175101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health