Provider Demographics
NPI:1417033051
Name:JACOB, JASON SANFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:SANFORD
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-761-4201
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000475162085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0345133OtherLABOR & INDUSTRY-TRA
WA1054847Medicaid
WA0230052OtherLABOR & INDUSTRY-TRA KING COUNTY
WA0230054OtherLABOR & INDUSTRY-UNION AVE
WA8946795OtherLABOR AND INDUSTRIES CRIME VICTIMS-UNION AVENUE OPEN MRI
WA0230052OtherLABOR AND INDUSTRIES-TRA
WA0249522OtherLABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST
WA8871221OtherPTAN-TRA KING CO
WA8871220OtherPTAN-TRA PIERCE CO