Provider Demographics
NPI:1790201598
Name:JACOBS, THOMAS LARUE (ARNP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LARUE
Last Name:JACOBS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29134 OLD RAINIER RD
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:OR
Mailing Address - Zip Code:97048-2300
Mailing Address - Country:US
Mailing Address - Phone:360-818-4677
Mailing Address - Fax:
Practice Address - Street 1:475 S COLUMBIA RIVER HWY STE 105
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-2860
Practice Address - Country:US
Practice Address - Phone:503-397-7119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60785555363LF0000X
AK153353363LF0000X
OR201707769NP-PP363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily