Provider Demographics
NPI:1588877062
Name:MATHEW, JACOB JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JOHN
Last Name:MATHEW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 220TH ST SW
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2177
Mailing Address - Country:US
Mailing Address - Phone:425-640-9777
Mailing Address - Fax:425-640-5122
Practice Address - Street 1:6920 220TH ST SW
Practice Address - Street 2:SUITE 106
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2177
Practice Address - Country:US
Practice Address - Phone:425-640-9777
Practice Address - Fax:425-640-5122
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002289103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical