Provider Demographics
NPI:1710490545
Name:JACOBY, JESSICA LYNN (PNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:JACOBY
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:JACOBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PNP
Mailing Address - Street 1:2404 NE 187TH PL
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6448
Mailing Address - Country:US
Mailing Address - Phone:616-638-5690
Mailing Address - Fax:
Practice Address - Street 1:2404 NE 187TH PL
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6448
Practice Address - Country:US
Practice Address - Phone:616-402-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003324208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics