Provider Demographics
NPI:1205419470
Name:POOLE, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:POOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15290 SW ROYALTY PKWY
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-4059
Mailing Address - Country:US
Mailing Address - Phone:971-256-4050
Mailing Address - Fax:
Practice Address - Street 1:15290 SW ROYALTY PKWY
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-4059
Practice Address - Country:US
Practice Address - Phone:971-256-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician