=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487930350
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERYL JACOBSON RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2011
-----------------------------------------------------
Last Update Date | 10/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 S WRIGHT STREET
-----------------------------------------------------
City | DELAVAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-728-3999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N5522 COBBLESTONE RD
-----------------------------------------------------
City | ELKHORN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-740-0982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 14361-40
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------