1093713992 NPI number — CORI L JACOBSON CNM

Table of content: CORI L JACOBSON CNM (NPI 1093713992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093713992 NPI number — CORI L JACOBSON CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBSON
Provider First Name:
CORI
Provider Middle Name:
L
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093713992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2142 N COVE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43606-3895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-291-8541
Provider Business Mailing Address Fax Number:
419-480-1340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PRESTON PLACE I 5180 CHAPPEL DRIVE
Provider Second Line Business Practice Location Address:
BUILDING B
Provider Business Practice Location Address City Name:
PERRYSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43551-7288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
567-585-0265
Provider Business Practice Location Address Fax Number:
419-873-6188
Provider Enumeration Date:
07/13/2005

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:  06073 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: NM-06073 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 344428256 . This is a "BEECH STREET" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000201559 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2223534 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05225 . This is a "PARAMOUNT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 344428256072 . This is a "CARESOURCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 344428256 . This is a "HEALTH NET" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4285606 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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