1174087605 NPI number — MRS. ANNIE L JACOBSON RDN, LN

Table of content: MRS. ANNIE L JACOBSON RDN, LN (NPI 1174087605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174087605 NPI number — MRS. ANNIE L JACOBSON RDN, LN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBSON
Provider First Name:
ANNIE
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDN, LN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERTRAND
Provider Other First Name:
ANNIE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RDN, LN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174087605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-328-9419
Provider Business Mailing Address Fax Number:
605-626-4251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3015 3RD AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57401-5418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-226-5500
Provider Business Practice Location Address Fax Number:
605-626-4251
Provider Enumeration Date:
01/29/2019

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: 133N00000X , with the licence number:  0358 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: 1066 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: 998682 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: 0358 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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