Provider Demographics
NPI:1366813230
Name:GUTAMA KULAS, JENNY LYNN (LICSW)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
Last Name:GUTAMA KULAS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3835
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3835
Mailing Address - Country:US
Mailing Address - Phone:206-548-3114
Mailing Address - Fax:206-762-6355
Practice Address - Street 1:2600 SW THISTLE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3748
Practice Address - Country:US
Practice Address - Phone:206-938-1360
Practice Address - Fax:206-935-6056
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW605905811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical