Basic Information
| Provider Information | |||||||||
| NPI: | 1003863663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 709 W ORCHARD DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603188800 | ||||||||
| FaxNumber: | 3603181085 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 ORCHARD PL | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606713900 | ||||||||
| FaxNumber: | 3606470882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00028253 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 423898022 | 01 | WA | GROUP HEALTH COOPERATIVE | OTHER | 080148055 | 01 | WA | RAILROAD MEDICARE | OTHER | 0130079 | 01 | WA | LABOR & INDUSTRIES (REG) | OTHER | 8127276 | 05 | WA | MEDICAID | 14535 | 01 | WA | REGENCE BLUESHIELD | OTHER | 8925030 | 01 | WA | LABOR & INDUSTRIES (CV) | OTHER |