1336667922 NPI number — DOLORES P, JACOBY M.S.W., D. DIV,PH.D.

Table of content: (NPI 1215384193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336667922 NPI number — DOLORES P, JACOBY M.S.W., D. DIV,PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBY
Provider First Name:
DOLORES
Provider Middle Name:
P,
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S.W., D. DIV,PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACOBY
Provider Other First Name:
DOLORES
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1336667922
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
716 VAN BUREN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT TOWNSEND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98368-8051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-385-8420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
716 VAN BUREN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT TOWNSEND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98368-8051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-385-8420
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  604151293 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP1600X , with the licence number: 604151293 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 604151293 . This is a "TRIWEST, VETERAN'S ADMINISTRATION" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 604151293 . This is a "VETERAN'S ADMINISTRATION" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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