Provider Demographics
NPI:1952879090
Name:CROOKS, JENNIFER ELAINE-KETCHAM (LSWAIC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE-KETCHAM
Last Name:CROOKS
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 42ND AVE SW APT 403
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-2557
Mailing Address - Country:US
Mailing Address - Phone:206-973-3791
Mailing Address - Fax:
Practice Address - Street 1:2331 42ND AVE SW APT 403
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-2557
Practice Address - Country:US
Practice Address - Phone:213-359-7984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL139171041C0700X
CA1155571041C0700X
MTBBH-LCSW-LIC-629321041C0700X
WALW610883391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORL13917OtherBOARD OF LICENSED SOCIAL WORKERS
WALW61088339OtherWASHINGTON DEPARTMENT OF HEALTH
MTBBH-LCSW-LIC-62932OtherBOARD OF BEHAVIORAL HEALTH
CA115557OtherBOARD OF BEHAVIORAL SCIENCES