Healthcare Provider Details

I. General information

NPI: 1134464993
Provider Name (Legal Business Name): CREEKSIDE SLEEP MEDICINE CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 112TH AVE NE STE 307
BELLEVUE WA
98004-3759
US

IV. Provider business mailing address

1380 112TH AVE NE STE 307
BELLEVUE WA
98004-3759
US

V. Phone/Fax

Practice location:
  • Phone: 425-278-2250
  • Fax: 425-562-5885
Mailing address:
  • Phone: 425-278-2250
  • Fax: 425-562-5885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TERESA E JACOBS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 425-278-2250