Provider Demographics
NPI:1861164584
Name:JACOBS, OLIVIA BROWN (LSWAIC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:BROWN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 19TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-4072
Mailing Address - Country:US
Mailing Address - Phone:206-709-7112
Mailing Address - Fax:
Practice Address - Street 1:500 19TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4072
Practice Address - Country:US
Practice Address - Phone:206-709-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2023-03-28
Deactivation Date:2021-10-21
Deactivation Code:
Reactivation Date:2023-03-28
Provider Licenses
StateLicense IDTaxonomies
390200000X
WASWIA.SC.61370612101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program