=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871995373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN JACOBS CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2014
-----------------------------------------------------
Last Update Date | 02/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 S FILLMORE ST
-----------------------------------------------------
City | OSCEOLA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50213-1619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-493-0195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1646 NW 99TH CT
-----------------------------------------------------
City | CLIVE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50325-6754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | D125471
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------