Healthcare Provider Details

I. General information

NPI: 1508354887
Provider Name (Legal Business Name): JACOB BENJAMIN BRENT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 COLBY AVE
EVERETT WA
98201-1665
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-7390
  • Fax:
Mailing address:
  • Phone: 866-747-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD61518406
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD61518406
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: