Healthcare Provider Details

I. General information

NPI: 1588093520
Provider Name (Legal Business Name): JACOB ADRIAN AYALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 S TACOMA WAY
TACOMA WA
98499-4456
US

IV. Provider business mailing address

6418 160TH AVENUE CT E APT E
SUMNER WA
98390-3068
US

V. Phone/Fax

Practice location:
  • Phone: 253-682-0320
  • Fax:
Mailing address:
  • Phone: 480-754-9552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberCG60414095
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: