Provider Demographics
NPI:1487914487
Name:JACOBSEN & SHAW, DDS, PLLC
Entity type:Organization
Organization Name:JACOBSEN & SHAW, DDS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:HEADLEY
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-381-0732
Mailing Address - Street 1:4915 25TH AVE NE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5667
Mailing Address - Country:US
Mailing Address - Phone:206-381-0732
Mailing Address - Fax:206-381-0513
Practice Address - Street 1:4915 25TH AVE NE
Practice Address - Street 2:SUITE 107
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5667
Practice Address - Country:US
Practice Address - Phone:206-381-0732
Practice Address - Fax:206-381-0513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60035233122300000X
WADE40021232122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty