Healthcare Provider Details

I. General information

NPI: 1780926097
Provider Name (Legal Business Name): ROBERT CONRAD JACOBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

IV. Provider business mailing address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-2836
  • Fax:
Mailing address:
  • Phone: 320-240-2836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberMD60833986
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD60833986
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: