NPIMap

Individual provider Active NPI

Charles D Jacobson, MD

  • Internal Medicine Physician
  • Puyallup, WA
National Provider Identifier
1124092754
Registry record updated Nov 8, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
MD00013535 Issued in WA
Practice address
1701 3Rd St SE
Puyallup, WA 98372-4511
Phone
(253) 967-5767
Fax
(253) 697-5682
NPI assigned
Feb 13, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 8, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X MD00013535 WA Primary

Addresses

Primary practice location

1701 3Rd St SE
Puyallup, WA 98372-4511

Mailing address

1701 3Rd St SE
Puyallup, WA 98372-4511
Phone (253) 967-5767

Other identifiers 4

IdentifierTypeStateIssuer
111661110OtherWAMEDICARE OTHER-INDIVIDUAL
1414200MedicaidWA
CO3401OtherWAMEDICARE OTHER-GROUP
193400000XOtherWATAXONOMY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MD00013535WAMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Good Samaritan Hospital Internal Medicine Current Accepting new patients
Puyallup Clinic Inc Past Accepting new patients
Frederick Health Hospital Inc Past Accepting new patients

Locations

407 14th Ave SE
Puyallup, WA 98372
Phone (253) 697-4000

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1139788800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1320710400000",
    "number": "1124092754",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1701 3RD ST SE",
            "city": "PUYALLUP",
            "state": "WA",
            "postal_code": "983724511",
            "telephone_number": "253-967-5767",
            "fax_number": "253-697-5682"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1701 3RD ST SE",
            "city": "PUYALLUP",
            "state": "WA",
            "postal_code": "983724511",
            "telephone_number": "253-967-5767",
            "fax_number": "253-697-5682"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACOBSON",
        "first_name": "CHARLES",
        "middle_name": "D",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-02-13",
        "last_updated": "2011-11-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "WA",
            "license": "MD00013535",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE OTHER-INDIVIDUAL",
            "identifier": "111661110",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1414200",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE OTHER-GROUP",
            "identifier": "CO3401",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAXONOMY",
            "identifier": "193400000X",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Puyallup, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.