Healthcare Provider Details

I. General information

NPI: 1457710089
Provider Name (Legal Business Name): KRYSTAL JACOBUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 04/27/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 NE 109TH AVE
VANCOUVER WA
98682-7749
US

IV. Provider business mailing address

3200 NE 109TH AVE
VANCOUVER WA
98682-7749
US

V. Phone/Fax

Practice location:
  • Phone: 360-695-1014
  • Fax: 360-750-1374
Mailing address:
  • Phone: 360-695-1014
  • Fax: 360-750-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60863847
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC6441
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: