Provider Demographics
NPI:1508350331
Name:JACOBSSON, MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JACOBSSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 YAKIMA AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5300
Mailing Address - Country:US
Mailing Address - Phone:253-552-1200
Mailing Address - Fax:253-552-1239
Practice Address - Street 1:1708 YAKIMA AVE STE 112
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5300
Practice Address - Country:US
Practice Address - Phone:253-552-1200
Practice Address - Fax:253-552-1239
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL61062440208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2159359Medicaid