Provider Demographics
NPI:1568229573
Name:JACOB, SARAH E (LPN, LMP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:E
Last Name:JACOB
Suffix:
Gender:F
Credentials:LPN, LMP
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:E
Other - Last Name:TYLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN, LMP
Mailing Address - Street 1:2710 SCHIRM LOOP RD NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9303
Mailing Address - Country:US
Mailing Address - Phone:360-790-0206
Mailing Address - Fax:
Practice Address - Street 1:307 W COTA ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2265
Practice Address - Country:US
Practice Address - Phone:360-205-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00052241251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care