Provider Demographics
NPI:1760760391
Name:JACOBI, SHANNON K (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:JACOBI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 N MAYFAIR RD STE 305
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4305
Mailing Address - Country:US
Mailing Address - Phone:414-384-6700
Mailing Address - Fax:414-727-1058
Practice Address - Street 1:3111 W RAWSON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9417
Practice Address - Country:US
Practice Address - Phone:414-384-6700
Practice Address - Fax:414-761-1921
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4466-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760760391Medicaid
WI1760760391Medicaid