Provider Demographics
NPI:1982882650
Name:HEAGLE, JOHN LEWIS (MA, JCL)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LEWIS
Last Name:HEAGLE
Suffix:
Gender:M
Credentials:MA, JCL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:GLENEDEN BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97388-0069
Mailing Address - Country:US
Mailing Address - Phone:541-764-2980
Mailing Address - Fax:541-764-2982
Practice Address - Street 1:4800 37TH AVE SW
Practice Address - Street 2:SUITE 210
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-2724
Practice Address - Country:US
Practice Address - Phone:206-923-4057
Practice Address - Fax:206-923-4001
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006716101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor