Provider Demographics
NPI:1124644356
Name:HENRY, ALEXANDRA JORDAN (LICSW)
Entity type:Individual
Prefix:MISS
First Name:ALEXANDRA
Middle Name:JORDAN
Last Name:HENRY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MISS
Other - First Name:ALEX
Other - Middle Name:JORDAN
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19316 BOTHELL WAY NE APT C101
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-6000
Mailing Address - Country:US
Mailing Address - Phone:805-368-9407
Mailing Address - Fax:
Practice Address - Street 1:707 S GRADY WAY
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3224
Practice Address - Country:US
Practice Address - Phone:425-496-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC611665701041C0700X
390200000X
WALW614768891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program