Provider Demographics
NPI:1780925198
Name:FOX, SPENCER JORDAN
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:JORDAN
Last Name:FOX
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 1:10333 MAIN ST APT 211
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6877
Mailing Address - Country:US
Mailing Address - Phone:425-802-2724
Mailing Address - Fax:
Practice Address - Street 1:10116 MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011
Practice Address - Country:US
Practice Address - Phone:425-802-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-09
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WAMG60675586106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health