Provider Demographics
NPI:1588093520
Name:AYALA, JACOB ADRIAN
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ADRIAN
Last Name:AYALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6418 160TH AVENUE CT E
Mailing Address - Street 2:APT E
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-3068
Mailing Address - Country:US
Mailing Address - Phone:480-754-9552
Mailing Address - Fax:
Practice Address - Street 1:9720 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98499-4456
Practice Address - Country:US
Practice Address - Phone:253-682-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60414095103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst