=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033910450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACOBS MH OF WASHINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2025
-----------------------------------------------------
Last Update Date | 03/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 NW GILMAN BLVD
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-694-3381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23993
-----------------------------------------------------
City | TIGARD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97281-3993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MADELINE JACOBS
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 503-694-3381
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------