Provider Demographics
NPI:1063297372
Name:JACOBSEN, TIMOTHY DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DANIEL
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3514
Practice Address - Country:US
Practice Address - Phone:509-946-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA363A00000X
WAPA61470203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant