Provider Demographics
NPI:1619985116
Name:JACOBSMA, SHELLEY ANN (RN)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:ANN
Last Name:JACOBSMA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 COLLEEN DR
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-7087
Mailing Address - Country:US
Mailing Address - Phone:651-653-5217
Mailing Address - Fax:
Practice Address - Street 1:255 SMITH AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2572
Practice Address - Country:US
Practice Address - Phone:651-292-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 099055-0163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse