Provider Demographics
NPI:1851786248
Name:JACOBSEN, KIMBERLY K (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:K
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 47159
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-0159
Mailing Address - Country:US
Mailing Address - Phone:763-559-3779
Mailing Address - Fax:763-450-3986
Practice Address - Street 1:14700 28TH AVE N STE 20
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4876
Practice Address - Country:US
Practice Address - Phone:763-559-3779
Practice Address - Fax:763-450-3986
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2024-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66773207LC0200X, 207L00000X
MN78154207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1851786248Medicaid