=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366101313
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB NATHAN CAMPBELL EMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2021
-----------------------------------------------------
Last Update Date | 12/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34515 9TH AVE S
-----------------------------------------------------
City | FEDERAL WAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98003-6799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-944-4137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19509 9TH AVE E
-----------------------------------------------------
City | SPANAWAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98387-8010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-848-7236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 146N00000X
-----------------------------------------------------
Taxonomy Name | Basic Emergency Medical Technician
-----------------------------------------------------
License Number | 7881-8076-2277
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------