Provider Demographics
NPI:1528368438
Name:JACOBS, EDMUND F JR (LMP)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:F
Last Name:JACOBS
Suffix:JR
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 1:31706 40TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:WA
Mailing Address - Zip Code:98580-8640
Mailing Address - Country:US
Mailing Address - Phone:206-369-0297
Mailing Address - Fax:
Practice Address - Street 1:31706 40TH AVE S
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:WA
Practice Address - Zip Code:98580-8640
Practice Address - Country:US
Practice Address - Phone:206-369-0297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60103665225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist