Provider Demographics
NPI:1497370001
Name:MEMMOTT, JACOB CHRISTOPHER (NP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CHRISTOPHER
Last Name:MEMMOTT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1424 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1720
Practice Address - Country:US
Practice Address - Phone:425-789-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61078651363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner