Provider Demographics
NPI:1114054947
Name:JACOBSON, CONNIE ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:ANN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 HERITAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-9404
Mailing Address - Country:US
Mailing Address - Phone:608-786-0900
Mailing Address - Fax:608-786-4418
Practice Address - Street 1:1529 HERITAGE BLVD
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-9404
Practice Address - Country:US
Practice Address - Phone:608-786-0900
Practice Address - Fax:608-786-4418
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4258-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist