Provider Demographics
NPI:1245761188
Name:DIANA JACOBS PHD. LICENSED PSYCHOLOGIST PS
Entity Type:Organization
Organization Name:DIANA JACOBS PHD. LICENSED PSYCHOLOGIST PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-734-7310
Mailing Address - Street 1:12 BELLWETHER WAY STE 220
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2914
Mailing Address - Country:US
Mailing Address - Phone:360-734-7310
Mailing Address - Fax:360-647-8336
Practice Address - Street 1:960 HARRIS AVE STE 205
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7025
Practice Address - Country:US
Practice Address - Phone:360-734-7310
Practice Address - Fax:360-647-8336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002516103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1790883353OtherNPI