1619153624 NPI number — DELLE JACOBS, LIMITED

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619153624 NPI number — DELLE JACOBS, LIMITED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELLE JACOBS, LIMITED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1619153624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
91 SNELLING AVE N
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104-6753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-642-9883
Provider Business Mailing Address Fax Number:
651-642-5909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 SNELLING AVE N
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-6753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-642-9883
Provider Business Practice Location Address Fax Number:
651-642-5909
Provider Enumeration Date:
01/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
DELLE
Authorized Official Middle Name:
MARIAN
Authorized Official Title or Position:
LICENSED SOCIAL WORKER
Authorized Official Telephone Number:
651-642-9883

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  699 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 1785 , 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)

  • Identifier: 298057600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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