Provider Demographics
NPI:1255391819
Name:JACOBSEN, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:JACOBSEN
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 1:505 NE 87TH AVE
Mailing Address - Street 2:STE. 460
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1989
Mailing Address - Country:US
Mailing Address - Phone:360-256-8865
Mailing Address - Fax:360-256-7127
Practice Address - Street 1:505 NE 87TH AVE
Practice Address - Street 2:STE. 460
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1989
Practice Address - Country:US
Practice Address - Phone:360-256-8865
Practice Address - Fax:360-256-7127
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000265012084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8150039Medicaid
WAE33381Medicare UPIN
WAG8887170Medicare PIN
WA8150039Medicaid