Provider Demographics
NPI:1942188735
Name:JACEZKO, MICHAEL THOMAS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:JACEZKO
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 1:430 12TH AVE E APT 207
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-5149
Mailing Address - Country:US
Mailing Address - Phone:314-707-6778
Mailing Address - Fax:
Practice Address - Street 1:1660 S COLUMBIAN WAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1532
Practice Address - Country:US
Practice Address - Phone:206-762-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA70012996235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist