Basic Information
| Provider Information | |||||||||
| NPI: | 1174720288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 E 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098382531 | ||||||||
| FaxNumber: | 5097556580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | M-13352 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60655741 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0359483 | 01 | WA | L&I-SWEDISH RADIA EDMONDS | OTHER | 0430161 | 01 | WA | L&I-VANCOUVER RADIOLOGY | OTHER | 2061893 | 05 | WA | MEDICAID | 1174720288 | 05 | ID | MEDICAID | 0415521 | 01 | WA | L&I-SOUTH SOUND RADIOLOGY | OTHER | 0359471 | 01 | WA | L&I-RADIA KING CTY | OTHER | 0359482 | 01 | WA | L&I-EVERGREEN RADIA | OTHER | 0359485 | 01 | WA | L&I-RADIA REST OF WA | OTHER | 0402063 | 01 | WA | L&I-SEATTLE RADIOLOGY | OTHER |