Provider Demographics
NPI:1194127746
Name:ROYAL, JACOB (NP-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ROYAL
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 LUCENA DR
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8370
Mailing Address - Country:US
Mailing Address - Phone:509-380-7378
Mailing Address - Fax:509-222-1289
Practice Address - Street 1:5015 LUCENA DR
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8370
Practice Address - Country:US
Practice Address - Phone:509-380-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60570569363LF0000X
NDR41002363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP60570569Medicaid