Provider Demographics
NPI:1881716595
Name:WICOMB, JEANNE HEATHER (LMFT)
Entity type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:HEATHER
Last Name:WICOMB
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 114TH AVE SE
Mailing Address - Street 2:THE MOORE CENTER, SUITE 180
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6950
Mailing Address - Country:US
Mailing Address - Phone:425-451-1134
Mailing Address - Fax:425-451-8501
Practice Address - Street 1:1601 114TH AVE SE
Practice Address - Street 2:SUITE 180
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6950
Practice Address - Country:US
Practice Address - Phone:425-451-1134
Practice Address - Fax:425-451-8501
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001898106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAW904633OtherCHAMPUS
WAA06149Medicare UPIN