Provider Demographics
NPI:1316954506
Name:TERRY L JACOBSON MD PLLC
Entity type:Organization
Organization Name:TERRY L JACOBSON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:COUWENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-932-9025
Mailing Address - Street 1:PO BOX 84702
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6002
Mailing Address - Country:US
Mailing Address - Phone:206-932-9025
Mailing Address - Fax:206-932-1929
Practice Address - Street 1:710 NW JUNIPER ST
Practice Address - Street 2:SUITE 204
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2717
Practice Address - Country:US
Practice Address - Phone:425-837-8842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8858507Medicare PIN