Provider Demographics
NPI:1336783893
Name:JACOBS, CHAD LAWRENCE (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:LAWRENCE
Last Name:JACOBS
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 1:2619 BAKER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3161
Mailing Address - Country:US
Mailing Address - Phone:317-695-8041
Mailing Address - Fax:
Practice Address - Street 1:21907 64TH AVE W STE 200
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-6200
Practice Address - Country:US
Practice Address - Phone:317-695-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004760363LP0808X
WAAP61025855363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health