Provider Demographics
NPI:1407573850
Name:JACOBS MENTAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:JACOBS MENTAL HEALTH SERVICES LLC
Other - Org Name:SKYCLOUD MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MADELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:503-694-3381
Mailing Address - Street 1:818 SW 3RD AVE # 221-5258
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-2405
Mailing Address - Country:US
Mailing Address - Phone:612-210-6965
Mailing Address - Fax:
Practice Address - Street 1:6700 SW 105TH AVE STE 203
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-8824
Practice Address - Country:US
Practice Address - Phone:503-694-3381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1447622477OtherNPI 1