Provider Demographics
NPI:1538165725
Name:JACOBSMEYER, DOUGLAS EDMUND (DC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EDMUND
Last Name:JACOBSMEYER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 RIVERSIDE DR
Mailing Address - Street 2:STE 105
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-5454
Mailing Address - Country:US
Mailing Address - Phone:360-424-6104
Mailing Address - Fax:360-424-6009
Practice Address - Street 1:2118 RIVERSIDE DR
Practice Address - Street 2:STE 105
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5454
Practice Address - Country:US
Practice Address - Phone:360-424-6104
Practice Address - Fax:360-424-6009
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2007-09-12
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
WACH00001611111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA11666OtherREGENCE BLUE CROSS
WA17631OtherLABOR AND INDUSTRIES
WA2088409Medicaid
WA11666OtherREGENCE BLUE CROSS