Healthcare Provider Details

I. General information

NPI: 1699453787
Provider Name (Legal Business Name): JACOB MULDOON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35020 SE KINSEY ST STE A
SNOQUALMIE WA
98065-8992
US

IV. Provider business mailing address

9800 ROOSEVELT WAY NE APT 26
SEATTLE WA
98115-2249
US

V. Phone/Fax

Practice location:
  • Phone: 425-831-2313
  • Fax:
Mailing address:
  • Phone: 425-445-9930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License NumberARNP.AP.61665929-NP
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberARNP.AP.61665929-NP
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberARNP.AP.61665929-NP
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License NumberARNP.AP.61665929-NP
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60935677
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: