Provider Demographics
NPI:1356436547
Name:JACOB, KRISTIN LIFFICK (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:LIFFICK
Last Name:JACOB
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15600 NE 8TH ST STE Q2
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-3956
Mailing Address - Country:US
Mailing Address - Phone:425-641-7482
Mailing Address - Fax:425-641-5802
Practice Address - Street 1:15600 NE 8TH SUITE Q2
Practice Address - Street 2:C/O PARIS MIKI OPTICAL
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008
Practice Address - Country:US
Practice Address - Phone:425-641-7482
Practice Address - Fax:425-641-5802
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00003683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8855078Medicare ID - Type Unspecified
WAV05975Medicare UPIN