1134241391 NPI number — NISHA LASSI JACOBS MD

Table of content: NISHA LASSI JACOBS MD (NPI 1134241391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134241391 NPI number — NISHA LASSI JACOBS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBS
Provider First Name:
NISHA
Provider Middle Name:
LASSI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LASSI
Provider Other First Name:
NISHA
Provider Other Middle Name:
KRISHAN
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:
1134241391
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11850 BLACKFOOT ST NW
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
COON RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-2598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-712-2100
Provider Business Mailing Address Fax Number:
763-712-2190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11850 BLACKFOOT ST NE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-2598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-712-2100
Provider Business Practice Location Address Fax Number:
763-712-2190
Provider Enumeration Date:
04/06/2007

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: 207RH0003X , with the licence number:  49898 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 49898 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 958440000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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