Basic Information
| Provider Information | |||||||||
| NPI: | 1821347311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 613 N BIRCH ST | ||||||||
| Address2: | |||||||||
| City: | CANBY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970133326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033413944 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1425 BEAVERCREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558471 | ||||||||
| FaxNumber: | 5036558595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2012 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 202100947NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.