Healthcare Provider Details

I. General information

NPI: 1659283810
Provider Name (Legal Business Name): MARY ANN JACOBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANN BUTCHER

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 KALE AVE
BRIDGEWATER IA
50837-7502
US

IV. Provider business mailing address

1131 KALE AVE
BRIDGEWATER IA
50837-7502
US

V. Phone/Fax

Practice location:
  • Phone: 641-261-4397
  • Fax:
Mailing address:
  • Phone: 641-261-4397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberP52516
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: