Provider Demographics
NPI:1457660383
Name:ALBRECQ, JACOB A (LMP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:ALBRECQ
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:WA
Mailing Address - Zip Code:98345-0660
Mailing Address - Country:US
Mailing Address - Phone:360-536-3820
Mailing Address - Fax:
Practice Address - Street 1:4060 WHEATON WAY
Practice Address - Street 2:SUITE C
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3500
Practice Address - Country:US
Practice Address - Phone:360-479-8477
Practice Address - Fax:360-479-8417
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60137530225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0277744OtherDEPT OF LABOR AND INDUSTRIES
12225979OtherCAQH PROVIDER ID