Healthcare Provider Details

I. General information

NPI: 1023216132
Provider Name (Legal Business Name): SANDRA ELLEN FORTUNA BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS SANDRA ELLEN JACOBSEN

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 3RD ST SW
WAGNER SD
57380-9675
US

IV. Provider business mailing address

513 3RD ST SW
WAGNER SD
57380-9675
US

V. Phone/Fax

Practice location:
  • Phone: 605-384-3418
  • Fax: 605-384-7228
Mailing address:
  • Phone: 605-384-7226
  • Fax: 605-384-7228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5044
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: