Provider Demographics
NPI:1518432145
Name:RUDICK, JACOB R (BA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:RUDICK
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6627 200TH ST SW APT J16
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5956
Mailing Address - Country:US
Mailing Address - Phone:304-629-6642
Mailing Address - Fax:
Practice Address - Street 1:851 POPLAR PL S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2827
Practice Address - Country:US
Practice Address - Phone:206-322-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health