Provider Demographics
NPI:1760814263
Name:JACOBSON, CORI JEAN (RDH)
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:JEAN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:CORI
Other - Middle Name:JEAN
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:804 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-1719
Mailing Address - Country:US
Mailing Address - Phone:605-224-7345
Mailing Address - Fax:605-224-0909
Practice Address - Street 1:804 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-1719
Practice Address - Country:US
Practice Address - Phone:605-224-7345
Practice Address - Fax:605-224-0909
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD124Q00000X124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist