1699865956 NPI number — MR. MICHAEL JOHN JACOBUS LMP, CTP

Table of content: MR. MICHAEL JOHN JACOBUS LMP, CTP (NPI 1699865956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699865956 NPI number — MR. MICHAEL JOHN JACOBUS LMP, CTP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBUS
Provider First Name:
MICHAEL
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMP, CTP
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:
1699865956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2366 EASTLAKE AVE E
Provider Second Line Business Mailing Address:
#439
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98102-3366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-949-1489
Provider Business Mailing Address Fax Number:
206-400-2787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2366 EASTLAKE AVE E
Provider Second Line Business Practice Location Address:
#439
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98102-3366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-949-1489
Provider Business Practice Location Address Fax Number:
206-400-2787
Provider Enumeration Date:
10/14/2006

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: 225700000X , with the licence number:  MA14730 , 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)





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