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General NPI Number Information
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NPI Number | 1790201598
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Entity Type | Individual
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Provider Name | THOMAS LARUE JACOBS ARNP
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Gender | Male
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Dates
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Enumeration Date | 08/14/2017
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Last Update Date | 02/17/2020
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Provider Practice Location Address
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Address Line | 475 S COLUMBIA RIVER HWY STE 105
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City | SAINT HELENS
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State | OR
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Zip | 97051-2860
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Country | US
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Telephone | 503-397-7119
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Fax |
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Provider Business Mailing Address
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Address Line | 29134 OLD RAINIER RD
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City | RAINIER
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State | OR
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Zip | 97048-2300
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Country | US
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Telephone | 360-818-4677
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP60785555
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 153353
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License Number State | AK
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 201707769NP-PP
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 201707769NP-PP
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License Number State | OR
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