Provider Demographics
NPI:1114391349
Name:KUTZKE, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:KUTZKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11526 30TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6861
Mailing Address - Country:US
Mailing Address - Phone:425-941-4222
Mailing Address - Fax:
Practice Address - Street 1:6400 SOUTHCENTER BLVD
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2547
Practice Address - Country:US
Practice Address - Phone:206-444-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-27
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60574492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health