Provider Demographics
NPI:1225854797
Name:WASHINGTON, JUSTIN LOUIS (MC61579349)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LOUIS
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:MC61579349
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11447 GRIFFIN PL
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-9534
Mailing Address - Country:US
Mailing Address - Phone:360-590-2304
Mailing Address - Fax:
Practice Address - Street 1:104 W 4TH ST STE 103
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-3932
Practice Address - Country:US
Practice Address - Phone:360-612-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61579349101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health