Healthcare Provider Details

I. General information

NPI: 1275042707
Provider Name (Legal Business Name): SHAUNA MARIE JACOBS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 W 17TH ST STE 101
SIOUX FALLS SD
57104-8805
US

IV. Provider business mailing address

3900 S LISANNE AVE
SIOUX FALLS SD
57103-7230
US

V. Phone/Fax

Practice location:
  • Phone: 605-328-8000
  • Fax: 605-328-8001
Mailing address:
  • Phone: 605-376-3213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCP001276
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: