Provider Demographics
NPI:1730602970
Name:KOOISTRA, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:KOOISTRA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 RAILROAD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5054
Mailing Address - Country:US
Mailing Address - Phone:360-676-2164
Mailing Address - Fax:360-676-2144
Practice Address - Street 1:725 E FAIRHAVEN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-1914
Practice Address - Country:US
Practice Address - Phone:360-856-3054
Practice Address - Fax:360-856-3065
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
WASC61454368101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor