Provider Demographics
NPI:1154617066
Name:GRADY, JENNIFER L (LMHC TEMP)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:GRADY
Suffix:
Gender:F
Credentials:LMHC TEMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12819 SE 38TH ST
Mailing Address - Street 2:#13
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-1326
Mailing Address - Country:US
Mailing Address - Phone:505-250-2946
Mailing Address - Fax:
Practice Address - Street 1:12819 SE 38TH ST
Practice Address - Street 2:#13
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-1326
Practice Address - Country:US
Practice Address - Phone:505-250-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0140741101Y00000X
NM0147261101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor