Provider Demographics
NPI:1447956586
Name:WOLLER, JACOB NICHOLAS (NP-BC)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:NICHOLAS
Last Name:WOLLER
Suffix:
Gender:M
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3518 212TH PL SE
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-6235
Mailing Address - Country:US
Mailing Address - Phone:425-736-3186
Mailing Address - Fax:
Practice Address - Street 1:3301 SQUALICUM PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1919
Practice Address - Country:US
Practice Address - Phone:360-788-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61382745363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily