1093552028 NPI number — JOLENE ELIZABETH JAKUBOWSKY CNM

Table of content: JOLENE ELIZABETH JAKUBOWSKY CNM (NPI 1093552028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093552028 NPI number — JOLENE ELIZABETH JAKUBOWSKY CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAKUBOWSKY
Provider First Name:
JOLENE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COYER/SIREK
Provider Other First Name:
JOLENE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093552028
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19781 EVERHILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55024-8676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-288-6584
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16802 145TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILACA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56353-3208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-362-0476
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  589 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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