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General NPI Number Information
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NPI Number | 1114833027
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Entity Type | Individual
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Provider Name | TYLER DOUGLAS JACOBSON
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Gender | Male
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Dates
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Enumeration Date | 08/20/2026
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Last Update Date | 08/20/2026
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Provider Practice Location Address
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Address Line | 2400 32ND AVE S STE 4
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City | FARGO
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State | ND
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Zip | 58103-5804
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Country | US
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Telephone | 701-234-9912
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Fax |
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Provider Business Mailing Address
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Address Line | 2400 32ND AVE S STE 4
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City | FARGO
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State | ND
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Zip | 58103-5804
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Country | US
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Telephone | 701-234-9912
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | 66876
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License Number State | ND
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