Provider Demographics
NPI:1366101313
Name:CAMPBELL, JACOB NATHAN (EMT)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:NATHAN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19509 9TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8010
Mailing Address - Country:US
Mailing Address - Phone:480-848-7236
Mailing Address - Fax:
Practice Address - Street 1:34515 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6799
Practice Address - Country:US
Practice Address - Phone:253-944-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7881-8076-2277146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic