Provider Demographics
NPI:1275168015
Name:DAVIDSON, JACOB BRYAN
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:BRYAN
Last Name:DAVIDSON
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 1:9901 NE 7TH AVE STE C116
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-4528
Mailing Address - Country:US
Mailing Address - Phone:360-571-2432
Mailing Address - Fax:
Practice Address - Street 1:9901 NE 7TH AVE STE C116
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-4528
Practice Address - Country:US
Practice Address - Phone:360-571-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWDL76118D13B106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician