Provider Demographics
NPI:1528093077
Name:JACOBSON, KEVIN S (NP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 ROBERTS AVE NE
Mailing Address - Street 2:COOPERSTOWN MEDICAL CENTER
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-7101
Mailing Address - Country:US
Mailing Address - Phone:701-797-2128
Mailing Address - Fax:
Practice Address - Street 1:1200 ROBERTS AVE NE
Practice Address - Street 2:COOPERSTOWN MEDICAL CENTER
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-7101
Practice Address - Country:US
Practice Address - Phone:701-797-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1561072363L00000X
NDR27650363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19682Medicaid
ND19682Medicaid