Provider Demographics
NPI:1013162098
Name:JACOBSEN, BRIAN JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAMES
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 1ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1842
Mailing Address - Country:US
Mailing Address - Phone:509-754-3262
Mailing Address - Fax:509-754-4975
Practice Address - Street 1:103 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-2197
Practice Address - Country:US
Practice Address - Phone:509-754-3262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60128176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist