Basic Information
| Provider Information | |||||||||
| NPI: | 1629463617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JETT | ||||||||
| FirstName: | LOLA | ||||||||
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| Credential: | SUDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 WETMORE AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982012927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252585270 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16715 AURORA AVE N # 102 | ||||||||
| Address2: | |||||||||
| City: | SHORELINE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981335310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065469766 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2015 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 60763564 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | CP60763564 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | CO 60521530 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.