Provider Demographics
NPI:1215767975
Name:STACK, JILL ELLEN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ELLEN
Last Name:STACK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 SW 118TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98146-2830
Mailing Address - Country:US
Mailing Address - Phone:808-348-1472
Mailing Address - Fax:
Practice Address - Street 1:101 ELLIOTT AVE W STE 500
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-4292
Practice Address - Country:US
Practice Address - Phone:808-348-1472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61593905363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health