P.O. Box 47877 Olympia, WA 98504-7877 360-236-4700 Credential Verification To be completed by the applicant: Please complete the top section of this form and send it to the state(s) and/or jurisdiction(s) where you are or have been licensed, certified, or registered as a healthcare provider. Instruct them to send the form directly to the address listed above. Note: Credentialing agencies may require a fee to verify a license, registration, or certification. Check in advance to help expedite the process. Applicant Demographics: First Name Middle Last Name
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