Provider Demographics
NPI:1295954998
Name:SOM, JACK ALLAN (RNFA)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:ALLAN
Last Name:SOM
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16506 NE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-8958
Mailing Address - Country:US
Mailing Address - Phone:360-609-2898
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER 400 NE
Practice Address - Street 2:MOTHER JOSEPH PLACE
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98668-9989
Practice Address - Country:US
Practice Address - Phone:360-514-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00061877364SP2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARN00061877OtherREGISTERED NURSE