Provider Demographics
NPI:1801008552
Name:JABBUSCH, MARK ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:JABBUSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 144TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-2324
Mailing Address - Country:US
Mailing Address - Phone:425-747-1059
Mailing Address - Fax:
Practice Address - Street 1:4505 144TH AVE SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-2324
Practice Address - Country:US
Practice Address - Phone:425-747-1059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015223207Q00000X
AK6721207Q00000X
WI55963-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1750801Medicaid
WA1750801Medicaid