1760657795 NPI number — DR. STEVEN ROBERT JACOBSEN DDS

Table of content: DR. STEVEN ROBERT JACOBSEN DDS (NPI 1760657795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760657795 NPI number — DR. STEVEN ROBERT JACOBSEN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBSEN
Provider First Name:
STEVEN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1760657795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4801 HWY 61
Provider Second Line Business Mailing Address:
#300
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-429-2299
Provider Business Mailing Address Fax Number:
651-429-6630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4801 HWY 61
Provider Second Line Business Practice Location Address:
#300
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-429-2299
Provider Business Practice Location Address Fax Number:
651-429-6630
Provider Enumeration Date:
04/30/2008

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: 1223P0300X , with the licence number:  9043 , 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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