Provider Demographics
NPI:1972208213
Name:JUSTUS, KATHERINE JELENE FOWLER (MA CCC SLP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JELENE FOWLER
Last Name:JUSTUS
Suffix:
Gender:
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13925 INTERURBAN AVE S STE 120
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-5718
Mailing Address - Country:US
Mailing Address - Phone:260-948-0096
Mailing Address - Fax:
Practice Address - Street 1:13925 INTERURBAN AVE S STE 120
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-5718
Practice Address - Country:US
Practice Address - Phone:260-948-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL61423994235Z00000X
OHSP.15644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist