Provider Demographics
NPI:1336603026
Name:GOMEZ, JASON RAYDR-SCOTT (SUDP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:RAYDR-SCOTT
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32020 LITTLE BOSTON RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9734
Mailing Address - Country:US
Mailing Address - Phone:360-297-6327
Mailing Address - Fax:360-925-3897
Practice Address - Street 1:31912 LITTLE BOSTON RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9700
Practice Address - Country:US
Practice Address - Phone:360-297-6329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-26
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60777486101YA0400X
WA61031153101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61031153OtherSUDP CREDINTENTIAL