Provider Demographics
NPI:1083909329
Name:MCLEOD, JACOB MYLES (DPM)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MYLES
Last Name:MCLEOD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 9TH AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2465
Mailing Address - Country:US
Mailing Address - Phone:360-501-3400
Mailing Address - Fax:360-423-5682
Practice Address - Street 1:625 9TH AVE STE 210
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2465
Practice Address - Country:US
Practice Address - Phone:360-501-3400
Practice Address - Fax:360-423-5682
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60466892213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0304956OtherWASHINGTON L&I
OR1083909329Medicaid
WA1083909329Medicaid
OR1083909329Medicaid