Provider Demographics
NPI:1578210415
Name:JACOBS, KRISTIN RENEE
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:RENEE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 S DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-5151
Mailing Address - Country:US
Mailing Address - Phone:360-591-1616
Mailing Address - Fax:
Practice Address - Street 1:301 E WISHKAH ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6514
Practice Address - Country:US
Practice Address - Phone:360-532-6320
Practice Address - Fax:360-533-1622
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60693794183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician