Provider Demographics
NPI:1912972258
Name:TOM, JACOB JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JOSEPH
Last Name:TOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:696 N SHEPHERD RD
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-8320
Mailing Address - Country:US
Mailing Address - Phone:360-281-6432
Mailing Address - Fax:
Practice Address - Street 1:960 N 16TH ST STE 103
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4175
Practice Address - Country:US
Practice Address - Phone:541-726-4694
Practice Address - Fax:541-744-6069
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA396312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287539Medicaid
OR287539Medicaid