Provider Demographics
NPI:1437319886
Name:JACOBS, ANN T (DDS)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:T
Last Name:JACOBS
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 1:122 COLFAX AVE SW
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1470
Mailing Address - Country:US
Mailing Address - Phone:218-631-4525
Mailing Address - Fax:
Practice Address - Street 1:122 COLFAX AVE SW
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1470
Practice Address - Country:US
Practice Address - Phone:218-631-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6239122300000X
MND12563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist