Provider Demographics
NPI:1275042707
Name:JACOBS, SHAUNA MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:MARIE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 S LISANNE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-7230
Mailing Address - Country:US
Mailing Address - Phone:605-376-3213
Mailing Address - Fax:
Practice Address - Street 1:1309 W 17TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-8805
Practice Address - Country:US
Practice Address - Phone:605-328-8000
Practice Address - Fax:605-328-8001
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001276363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner