Basic Information
| Provider Information | |||||||||
| NPI: | 1588620843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1875 WOODWINDS DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512326700 | ||||||||
| FaxNumber: | 6512326711 | ||||||||
| Practice Location | |||||||||
| Address1: | 1875 WOODWINDS DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512326700 | ||||||||
| FaxNumber: | 6512326711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | R076307-5 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.