Provider Demographics
NPI:1992532790
Name:JACOBSON, RODDY
Entity type:Individual
Prefix:
First Name:RODDY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4128 SE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3934
Mailing Address - Country:US
Mailing Address - Phone:770-853-7525
Mailing Address - Fax:
Practice Address - Street 1:8285 SW NIMBUS AVE STE 148
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-6465
Practice Address - Country:US
Practice Address - Phone:503-352-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator