Provider Demographics
NPI:1750716155
Name:JUNGBLUTH, NATHANIEL JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:JOHN
Last Name:JUNGBLUTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19803 NORTH CREEK PKWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011
Mailing Address - Country:US
Mailing Address - Phone:425-954-6038
Mailing Address - Fax:425-481-2157
Practice Address - Street 1:19803 NORTH CREEK PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011
Practice Address - Country:US
Practice Address - Phone:425-954-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60373417103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical