Provider Demographics
NPI:1700047131
Name:JACOBSEN, RONI MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:RONI
Middle Name:MARIE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13123 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:720-777-3365
Practice Address - Fax:720-777-7178
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00587032080P0202X, 207RA0002X
WI57002208000000X
AZ70805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700047131Medicaid
WI73601 2428Medicare PIN
WI68086 1232Medicare PIN