=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699395863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN BAY DOULAS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2020
-----------------------------------------------------
Last Update Date | 04/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 437 S JACKSON ST RM 130
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-246-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1851
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54305-1851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-246-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, CERTIFIED DOULA
-----------------------------------------------------
Name | EMILY JACOBSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-246-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374J00000X
-----------------------------------------------------
Taxonomy Name | Doula
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------