Provider Demographics
NPI:1114106945
Name:TERESA E. JACOBS, MD, PS
Entity type:Organization
Organization Name:TERESA E. JACOBS, MD, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-278-2250
Mailing Address - Street 1:PO BOX 5593
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5500
Mailing Address - Country:US
Mailing Address - Phone:425-278-2250
Mailing Address - Fax:425-562-5885
Practice Address - Street 1:1380 112TH AVE NE STE 307
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3759
Practice Address - Country:US
Practice Address - Phone:425-278-2250
Practice Address - Fax:425-562-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029806207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0538JAOtherREGENCE #
WAAB34037OtherMEDICARE ID #
WA1117050Medicaid
WAE24703Medicare UPIN
WAAB34037OtherMEDICARE ID #