Basic Information
Provider Information | |||||||||
NPI: | 1689097990 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBS | ||||||||
FirstName: | ALLISON | ||||||||
MiddleName: | JOY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 442 SW UMATILLA AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | REDMOND | ||||||||
State: | OR | ||||||||
PostalCode: | 977567039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418262525 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1616 CORNWALL AVE STE 205 | ||||||||
Address2: |   | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982254642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3606766177 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2014 | ||||||||
LastUpdateDate: | 01/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D10767 | OR | N |   | Dental Providers | Dentist | General Practice | 122300000X | DE 60389264 | WA | Y |   | Dental Providers | Dentist |   |
No ID Information.