Provider Demographics
NPI:1679634281
Name:JACOBS, LORI JEAN (RPH)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:JEAN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 DOVE LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1460
Mailing Address - Country:US
Mailing Address - Phone:509-758-5438
Mailing Address - Fax:
Practice Address - Street 1:1275 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2846
Practice Address - Country:US
Practice Address - Phone:509-758-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6173801Medicaid
WA4902981OtherNABP