Provider Demographics
NPI:1093688764
Name:WILLIS, JEREMIAH
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:WILLIS
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 1:719 SW 356TH PL
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-8133
Mailing Address - Country:US
Mailing Address - Phone:253-241-9390
Mailing Address - Fax:
Practice Address - Street 1:4311 11TH AVE NE STE 200
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6367
Practice Address - Country:US
Practice Address - Phone:206-616-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-27
Last Update Date:2025-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program