Provider Demographics
NPI:1073589834
Name:JACOBSEN, PAULA MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:MARIE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:MARIE
Other - Last Name:SANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNP
Mailing Address - Street 1:2400 S. MINNESOTA AVE.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-3762
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:
Practice Address - Street 1:1417 S. CLIFF AVE.
Practice Address - Street 2:STE. 401
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1064
Practice Address - Country:US
Practice Address - Phone:605-322-8920
Practice Address - Fax:605-322-8919
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000441363LF0000X
IAA-127382363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12262Medicaid
SD4992623OtherBLUE CROSS
SD9237791OtherDAKOTACARE
MN37L32SAOtherCC SYSTEMS/ BLUE PLUS
SD6828076Medicaid
769201045265OtherPREFERRED ONE
SD102157Medicaid
SD57105F019OtherWPS TRICARE
P00448581OtherRR MEDICARE
IA0596684Medicaid
MN37L32SAOtherBLUE CROSS
1073589834OtherARAZ/AMERICA'S PPO
1073589834OtherARAZ/AMERICA'S PPO
SD6828076Medicaid
SDS102830Medicare PIN