Basic Information
| Provider Information | |||||||||
| NPI: | 1073589834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSEN | ||||||||
| FirstName: | PAULA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANDERSON | ||||||||
| OtherFirstName: | PAULA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2400 S. MINNESOTA AVE. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571053762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1417 S. CLIFF AVE. | ||||||||
| Address2: | STE. 401 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053228920 | ||||||||
| FaxNumber: | 6053228919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CP000441 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A-127382 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 12262 | 05 | ND | MEDICAID | 4992623 | 01 | SD | BLUE CROSS | OTHER | 9237791 | 01 | SD | DAKOTACARE | OTHER | 37L32SA | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | 6828076 | 05 | SD | MEDICAID | 769201045265 | 01 | PREFERRED ONE | OTHER | 102157 | 05 | SD | MEDICAID | 57105F019 | 01 | SD | WPS TRICARE | OTHER | P00448581 | 01 | RR MEDICARE | OTHER | 0596684 | 05 | IA | MEDICAID | 37L32SA | 01 | MN | BLUE CROSS | OTHER | 1073589834 | 01 | ARAZ/AMERICA'S PPO | OTHER |