Provider Demographics
NPI:1174720288
Name:HARRIS, JACOB DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DANIEL
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:400 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1334
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:509-755-6580
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-133522085R0202X
WAMD606557412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0359483OtherL&I-SWEDISH RADIA EDMONDS
WA0430161OtherL&I-VANCOUVER RADIOLOGY
WA2061893Medicaid
ID1174720288Medicaid
WA0415521OtherL&I-SOUTH SOUND RADIOLOGY
WA0359471OtherL&I-RADIA KING CTY
WA0359482OtherL&I-EVERGREEN RADIA
WA0359485OtherL&I-RADIA REST OF WA
WA0402063OtherL&I-SEATTLE RADIOLOGY