Provider Demographics
NPI:1669919148
Name:JACOB, PATRICE ALANA (PHD)
Entity type:Individual
Prefix:DR
First Name:PATRICE
Middle Name:ALANA
Last Name:JACOB
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 S 15TH WAY
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-7826
Mailing Address - Country:US
Mailing Address - Phone:360-643-9217
Mailing Address - Fax:503-678-9751
Practice Address - Street 1:1361 S 15TH WAY
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-7826
Practice Address - Country:US
Practice Address - Phone:360-643-9217
Practice Address - Fax:503-678-9751
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60704526101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2082041Medicaid