Basic Information
| Provider Information | |||||||||
| NPI: | 1457660383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALBRECQ | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660 | ||||||||
| Address2: | |||||||||
| City: | KEYPORT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983450660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605363820 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4060 WHEATON WAY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604798477 | ||||||||
| FaxNumber: | 3604798417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2010 | ||||||||
| LastUpdateDate: | 05/16/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA60137530 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0277744 | 01 | WA | DEPT OF LABOR AND INDUSTRIES | OTHER | 12225979 | 01 | CAQH PROVIDER ID | OTHER |