Healthcare Provider Details

I. General information

NPI: 1588225528
Provider Name (Legal Business Name): JOSHUA JACOBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 W WASHINGTON AVE STE 117
YAKIMA WA
98903-1367
US

IV. Provider business mailing address

PO BOX 8051
YAKIMA WA
98908-0051
US

V. Phone/Fax

Practice location:
  • Phone: 509-452-8418
  • Fax:
Mailing address:
  • Phone: 509-469-1903
  • Fax: 509-469-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberRT60107255
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberRT60107255
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: