Healthcare Provider Details

I. General information

NPI: 1962321729
Provider Name (Legal Business Name): ALPHONSO S JACOBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3548 47TH ST S APT 201
FARGO ND
58104-4008
US

IV. Provider business mailing address

3548 47TH ST S APT 201
FARGO ND
58104-4008
US

V. Phone/Fax

Practice location:
  • Phone: 701-720-5588
  • Fax:
Mailing address:
  • Phone: 701-720-5588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number53989
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: