Provider Demographics
NPI:1942711312
Name:VERMEERSCH, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VERMEERSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1467 FORD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-3911
Mailing Address - Country:US
Mailing Address - Phone:909-583-4040
Mailing Address - Fax:
Practice Address - Street 1:301 S 320TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5200
Practice Address - Country:US
Practice Address - Phone:253-874-7000
Practice Address - Fax:866-559-3952
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WAPY61402805103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst