MEDICARE: JACOB MCEWEN MA, LMFTA

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	106H00000X	Marriage & Family Therapist	MG61449528	WA

General Provider Information

NPI Number	:	1962282731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MCEWEN MA, LMFTA

Provider Business Mailing Address
First Line	:	1204 E AUGUSTA AVE
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99207-2438
Country	:	US
Telephone Number	:	208-741-0107
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 S GRAND BLVD STE 201
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99203-5001
Country	:	US
Telephone Number	:	509-209-9664
Fax Number	:

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

Provider Enumeration Date	:	09/29/2023
Last Update Date	:	09/29/2023

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