Basic Information
Provider Information | |||||||||
NPI: | 1053405662 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBSEN | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 HIGHWAY 12 | ||||||||
Address2: |   | ||||||||
City: | HETTINGER | ||||||||
State: | ND | ||||||||
PostalCode: | 586397533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7015676130 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1000 HIGHWAY 12 | ||||||||
Address2: |   | ||||||||
City: | HETTINGER | ||||||||
State: | ND | ||||||||
PostalCode: | 58639 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7015674561 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2916 | ND | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 123993 | 01 |   | WORKERS COMP | OTHER | 12564 | 05 | ND |   | MEDICAID | 10775 | 01 |   | ND BC/BS | OTHER | 20818 | 01 |   | SIOUX VALLEY | OTHER | 3018140 | 05 | WA |   | MEDICAID | 45034068812 | 05 | NE |   | MEDICAID | 7774910 | 05 | SD |   | MEDICAID |