Provider Demographics
NPI:1801663067
Name:MAHNKE, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MAHNKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:MAHNKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3805 SE 182ND CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8269
Mailing Address - Country:US
Mailing Address - Phone:360-831-7989
Mailing Address - Fax:
Practice Address - Street 1:448 N WERTH BLVD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7500
Practice Address - Country:US
Practice Address - Phone:503-554-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant