Provider Demographics
NPI:1780754044
Name:JACOBSON, JANIS ANN (LMP)
Entity type:Individual
Prefix:
First Name:JANIS
Middle Name:ANN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13153
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-1003
Mailing Address - Country:US
Mailing Address - Phone:206-824-0107
Mailing Address - Fax:206-870-6812
Practice Address - Street 1:22760 MARINE VIEW DR S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-8408
Practice Address - Country:US
Practice Address - Phone:206-824-0107
Practice Address - Fax:206-870-6812
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017566174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist