Provider Demographics
NPI:1124704895
Name:STRADLING, JACOB RYAN (PMHNP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:STRADLING
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 LACLAIR ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2988
Mailing Address - Country:US
Mailing Address - Phone:541-266-6700
Mailing Address - Fax:541-888-8726
Practice Address - Street 1:281 LACLAIR ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2988
Practice Address - Country:US
Practice Address - Phone:541-266-6733
Practice Address - Fax:541-888-8726
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10045770363LP0808X
AZ294125363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health