Provider Demographics
NPI:1205866894
Name:JACOBS, CORY D (DC, PA-C)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:D
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 FELTL RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7983
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:5435 FELTL RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-7983
Practice Address - Country:US
Practice Address - Phone:952-835-9880
Practice Address - Fax:952-857-1554
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4744111N00000X
MN12171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1205866894Medicaid
MNH400370871Medicare PIN
WI000370275Medicare PIN
MN813937700Medicaid