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NPI Code Detail

MEDICARE: JACOB LEE PRATT

MEDICARE: JACOB LEE PRATT
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
1171M00000XCase Manager/Care Coordinator

General Provider Information

NPI Number : 1366087991
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB LEE PRATT
Provider Business Mailing Address
First Line : 18417 SE OAK ST
Second Line :
City : PORTLAND
State : OR
Zip : 97233-4850
Country : US
Telephone Number : 503-661-5455
Fax Number :
Provider Business Practice Location Address
First Line : 18417 SE OAK ST
Second Line :
City : PORTLAND
State : OR
Zip : 97233-4850
Country : US
Telephone Number : 503-661-5455
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/06/2019
Last Update Date : 11/06/2019

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