Provider Demographics
NPI:1447622477
Name:JACOBS, MADELINE (PMHNP, RN, BSN)
Entity type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PMHNP, RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23993
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3993
Mailing Address - Country:US
Mailing Address - Phone:503-694-3381
Mailing Address - Fax:503-386-3293
Practice Address - Street 1:13568 SE 97TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6668
Practice Address - Country:US
Practice Address - Phone:503-694-3381
Practice Address - Fax:503-386-3293
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201504614RN163WP0807X
OR201809753NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent