1538165725 NPI number — DOUGLAS EDMUND JACOBSMEYER DC

Table of content: (NPI 1043913395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538165725 NPI number — DOUGLAS EDMUND JACOBSMEYER DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBSMEYER
Provider First Name:
DOUGLAS
Provider Middle Name:
EDMUND
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538165725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2118 RIVERSIDE DR
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98273-5454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-424-6104
Provider Business Mailing Address Fax Number:
360-424-6009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2118 RIVERSIDE DR
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273-5454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-424-6104
Provider Business Practice Location Address Fax Number:
360-424-6009
Provider Enumeration Date:
06/22/2005

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: 111N00000X , with the licence number:  CH00001611 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11666 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 17631 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2088409 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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