Provider Demographics
NPI:1174087605
Name:JACOBSON, ANNIE L (RDN, LN)
Entity type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:L
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:RDN, LN
Other - Prefix:MISS
Other - First Name:ANNIE
Other - Middle Name:L
Other - Last Name:BERTRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LN
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9419
Mailing Address - Fax:605-626-4251
Practice Address - Street 1:3015 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-5418
Practice Address - Country:US
Practice Address - Phone:605-226-5500
Practice Address - Fax:605-626-4251
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0358133N00000X, 133V00000X
ND1066133V00000X
998682133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist