Provider Demographics
NPI:1821347311
Name:JACOBY, KIMBERLY ANN (PNP-PC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:JACOBY
Suffix:
Gender:F
Credentials:PNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 N BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3326
Mailing Address - Country:US
Mailing Address - Phone:503-341-3944
Mailing Address - Fax:
Practice Address - Street 1:1425 BEAVERCREEK ROAD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4023
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:503-655-8595
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202100947NP-PP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics