Provider Demographics
NPI:1497028823
Name:EPHRAIM, JC JR (CCC, SUDP, MHP,)
Entity type:Individual
Prefix:
First Name:JC
Middle Name:
Last Name:EPHRAIM
Suffix:JR
Gender:M
Credentials:CCC, SUDP, MHP,
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 6385
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98064-6385
Mailing Address - Country:US
Mailing Address - Phone:206-650-4024
Mailing Address - Fax:
Practice Address - Street 1:15 S GRADY WAY STE 310
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3215
Practice Address - Country:US
Practice Address - Phone:206-726-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL60461451101YM0800X
WACP00001663101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)