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General NPI Number Information
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NPI Number | 1699458927
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Entity Type | Individual
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Provider Name | JACOB JOHN MASSARELLI PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/11/2023
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Last Update Date | 10/19/2023
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Provider Practice Location Address
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Address Line | 1800 COOKS HILL RD STE F
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City | CENTRALIA
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State | WA
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Zip | 98531-9162
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Country | US
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Telephone | 360-669-0335
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Fax | 360-736-2967
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Provider Business Mailing Address
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Address Line | 2690 NE KRESKY AVE
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City | CHEHALIS
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State | WA
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Zip | 98532-2412
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Country | US
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Telephone | 360-330-9595
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Fax | 360-330-9560
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA61478292
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License Number State | WA
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