MEDICARE: JACOB LEASE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1174343180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB LEASE

Provider Business Mailing Address
First Line	:	21204 NW 31ST AVE
Second Line	:
City	:	RIDGEFIELD
State	:	WA
Zip	:	98642-8523
Country	:	US
Telephone Number	:	509-342-9341
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 NW 12TH AVE STE 107
Second Line	:
City	:	BATTLE GROUND
State	:	WA
Zip	:	98604-9141
Country	:	US
Telephone Number	:	360-723-0528
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2024
Last Update Date	:	02/13/2026

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Directions to “ JACOB LEASE ” Practice Location

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