Provider Demographics
NPI:1659714970
Name:SMITH, JACOB C
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:BOX 357115
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7115
Mailing Address - Country:US
Mailing Address - Phone:206-598-7200
Mailing Address - Fax:206-598-7690
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:BOX 357115
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7200
Practice Address - Country:US
Practice Address - Phone:206-598-7200
Practice Address - Fax:206-598-7690
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD605855512085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2027913Medicaid