Healthcare Provider Details

I. General information

NPI: 1659714970
Provider Name (Legal Business Name): DR. JACOB C SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST BOX 357115
SEATTLE WA
98195-7200
US

IV. Provider business mailing address

1959 NE PACIFIC ST BOX 357115
SEATTLE WA
98195-7115
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-7200
  • Fax: 206-598-7690
Mailing address:
  • Phone: 206-598-7200
  • Fax: 206-598-7690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD60585551
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD60585551
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: