Provider Demographics
NPI:1063583060
Name:WULF, JONATHAN B (PSYD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:WULF
Suffix:
Gender:M
Credentials:PSYD
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 84026
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-8426
Mailing Address - Country:US
Mailing Address - Phone:206-386-6111
Mailing Address - Fax:
Practice Address - Street 1:1401 MADISON ST STE 100
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1316
Practice Address - Country:US
Practice Address - Phone:206-386-6111
Practice Address - Fax:206-386-6113
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002329103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8400772Medicaid
WAAB20672Medicare PIN