Provider Demographics
NPI:1639641350
Name:JACOBS, CINDY C (MEDICAL TECHNOLOGIST)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:C
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MEDICAL TECHNOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8114
Mailing Address - Country:US
Mailing Address - Phone:605-355-2228
Mailing Address - Fax:605-355-2514
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-355-2228
Practice Address - Fax:605-355-2514
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD04005569246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549050OtherMEDICAID
SD0140070Medicaid