Healthcare Provider Details

I. General information

NPI: 1992273924
Provider Name (Legal Business Name): JACOB MICHAEL BRANSCUM-HIGUERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 S LEWIS ST STE 200
MONROE WA
98272-2350
US

IV. Provider business mailing address

1937 W 5TH ST
PORT ANGELES WA
98363-1605
US

V. Phone/Fax

Practice location:
  • Phone: 425-224-6123
  • Fax:
Mailing address:
  • Phone: 564-203-6464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.70014326
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: