Provider Demographics
NPI:1467941211
Name:HERNICK, JACOBY JOANNE (DDS)
Entity Type:Individual
Prefix:
First Name:JACOBY
Middle Name:JOANNE
Last Name:HERNICK
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 1:1827 36TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4581
Mailing Address - Country:US
Mailing Address - Phone:612-532-0046
Mailing Address - Fax:
Practice Address - Street 1:816 W SAINT GERMAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3511
Practice Address - Country:US
Practice Address - Phone:320-252-2454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001932-151223G0001X
390200000X
MND144811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program