Provider Demographics
NPI:1659741304
Name:DUBOSE, JESSICA MT (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MT
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2603
Mailing Address - Country:US
Mailing Address - Phone:206-630-1680
Mailing Address - Fax:
Practice Address - Street 1:1200 SW 27TH ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2603
Practice Address - Country:US
Practice Address - Phone:206-630-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW602055961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW60205596OtherLICENSED INDEPENDENT CLINICAL SOCIAL WORKER LICENSE